Holden Rehabilitation & Nursing Center

F-F740.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 225002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Holden Rehabilitation & Nursing Center 32 Mayo Road Holden, MA 01520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45429

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter for one Resident (#36) out of a total sample of 22 residents.

Specifically, for Resident #36, the facility failed to ensure that a blocked indwelling urinary catheter was replaced with the correct sized catheter balloon as ordered by the Physician.

Findings include:

Review of the facility policy for Catheter Care, Urinary, updated 12/12/24, indicated:

>Preparation

-Review the resident's care plan to assess for any special needs of the resident.

-Assemble the equipment and supplies as needed.

>Reporting

-Report other information in accordance with facility policy and professional standards of practice.

Resident #36 was admitted to the facility in September 2023 with diagnoses including Multiple Sclerosis, Quadriplegia and Neurogenic Bladder.

Review of the Resident's care plan for a Foley Catheter, last revised 9/24/24, indicated:

-Change Foley catheter as needed (PRN).

-Foley catheter care per facility protocol every shift, and as needed.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated that Resident #36:

-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of 15.

-was dependent for toileting

-had an indwelling urinary catheter.

Review of Resident #36's February 2025 Physician's orders indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 225002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Holden Rehabilitation & Nursing Center 32 Mayo Road Holden, MA 01520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -Foley catheter size 20 French (Fr: French scale or system used to size catheters) with 10 milliliter (ml) balloon, change every 3 months as needed for blockage or leakage, start date 8/11/24. Level of Harm - Minimal harm or potential for actual harm -Foley catheter 20 Fr with 10 ml (balloon), change every 3 months . change with same size catheter, start date 9/5/24 Residents Affected - Few

Review of Resident #36's February 2025 Treatment Administration Record (TAR) indicated:

-Foley catheter size 20 Fr with a 10 ml balloon.

-the Foley catheter had been changed to a size 20 Fr with a 10 ml balloon as needed for a blockage or leakage on 2/1/25.

Review of Resident #36's clinical record indicated a Nursing Progress Note dated 2/1/25, that indicated:

-the Resident's Foley catheter had been changed due to a blockage.

-the Foley catheter size was changed to a 20 Fr with a 10 ml balloon.

On 2/13/25 at 9:21 A.M., the surveyor and Unit Manager (UM) #2 observed that Resident #36 had a Foley catheter in place that was a size 20 Fr with a 30 ml balloon. The surveyor and UM #2 also observed a red colored substance on the towel next to the Resident's right leg. During an interview at the time, UM #2 said that the size of the catheter and balloon should reflect what was ordered by the Physician and it did not. UM #2 further said that having a larger balloon size can cause irritation and increase the chances of bleeding to

the Resident.

During an interview on 2/13/25 at 10:53 A.M., the Director of Nursing (DON) said the facility should have supply of the correct size urinary catheters for all the residents who needed them.

During an interview on 2/13/25 at 12:48 P.M., UM #2 said that she had no documented evidence that the wrong balloon size urinary catheter had been placed in Resident #36 on 2/1/25 until 2/13/25, after the initial

observation with the surveyor.

During an interview on 2/13/25 at 12:54 P.M., the Nurse Practitioner (NP) said that she does receive phone calls from the Nurses if they do not have the correct size catheter equipment and need to change the sizing of urinary catheter. The NP also said that in the case where the correct size catheter balloon was not available, an order should be written to reflect the new catheter balloon size change and this was not done.

During an interview on 2/13/25 at 12:57 P.M., Central Supply Staff said that he did not have Foley catheters size 20 Fr with 10 ml balloon on hand until they were delivered to the facility today. Central Supply Staff also said that he was unable to provide evidence on how long the facility had been without 20 Fr/10 ml balloon size urinary catheter. Central Supply Staff said that he was responsible for ordering the building's medical supplies and he is informed of what supplies to order by a list created by the nursing staff on each of the units.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 225002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Holden Rehabilitation & Nursing Center 32 Mayo Road Holden, MA 01520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm 42761

Residents Affected - Few Based on interview, and record review, the facility failed to provide Behavioral Health Care and services to attain or maintain the highest practicable mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one Resident (#16) out of a total sample of 22 residents.

Specifically, for Resident #16, the facility failed to:

-obtain psychotherapeutic counseling based on recommendations of a Psychotherapy Evaluation, and consent for the therapy by the Resident.

-obtain a Psychiatric evaluation timely for the Resident when the Nurse Practitioner ordered a Psychiatric Evaluation to assess the Resident for auditory hallucinations.

Findings include:

Review of the facility's policy titled Behavioral Health Services, undated, indicated the following:

-The facility will provide and residents will receive behavioral health services as needed to attain or maintain

the highest practicable . mental and psychosocial well-being in accordance with the . plan of care.

-Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care.

Resident #16 was admitted to the facility in May 2022 with diagnoses including Major Depressive Disorder and Mild Cognitive Impairment.

Review of Resident #16's active Physician orders dated 5/6/22, indicated:

-Dentist, Podiatry, Optometrist, Audiology, Behavioral Health, and Wound MD (Physician) with Resident/family consent as needed.

Review of Resident #16's Mood Care Plan, initiated 5/6/22, indicated the following:

-The Resident had potential for alteration in coping and mood related to a diagnosis of MDD (Major Depressive Disorder), periods of agitation at times, and feeling down on occasion.

-Monitor for mood and behavior changes and report to SW (Social Worker) and Nursing for follow-up as indicated (5/6/22).

-Obtain Psychological/Psychiatric Consult/Services if indicated (5/6/22).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 225002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Holden Rehabilitation & Nursing Center 32 Mayo Road Holden, MA 01520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Review of Resident #16's Behavioral Health Psychotherapy Evaluation Note, dated 11/3/23, indicated:

Level of Harm - Minimal harm or -The Resident was referred to Psychotherapy for counseling. potential for actual harm -An initial evaluation was being conducted. Residents Affected - Few -The Resident reported someone was messing with him/her through the phone and from the hallway, calling his/her name.

-The rationale for therapy included identifying changing of negative or repetitive thoughts, engage in or

review new interpersonal skills and self management (grounding) activities to control those thoughts .

-The Resident agreed with the treatment plan.

Review of Resident #16's Behavioral Health Consent, dated 11/3/23, indicated the Resident consented to psychotherapy services.

Review of Resident #16's clinical record did not include any evidence that the Resident received psychotherapeutic counseling after his/her evaluation on 11/3/23.

Review of Resident #16's Attending Physician Request for Services/Consultation, dated 12/14/23, indicated

a request for Behavioral Health Services relative to Dementia and a question of the Resident experiencing auditory hallucinations.

Review of Resident #16's Nurse Practitioner (NP) orders, dated 12/14/23, indicated:

-Obtain psych (Psychiatric) eval and audiology consult.

Review of Resident #16's Audiology Consult, dated 2/1/24, indicated the Resident:

-had hearing loss

-reported tinnitus (ringing or buzzing in ears)

-had hearing aids recommended

-had been referred to Behavioral Health Services for a change in behavior and hearing sounds.

-reported tinnitus in the left ear.

Review of Resident #16's Physician Progress Note, dated 3/6/24, indicated:

-The Resident had some issues with staff overnight relative to staff talking through the intercom.

-The Resident had mild cognitive impairment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 225002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Holden Rehabilitation & Nursing Center 32 Mayo Road Holden, MA 01520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 -It was unclear whether the Resident was having delusions.

Level of Harm - Minimal harm or -The Resident had been seen by Psych Services. potential for actual harm

Review of Resident #16's clinical record did not include any evidence that the Resident was seen by Residents Affected - Few Psychiatric Services since the Behavioral Health Psychotherapy Evaluation on 11/3/23.

Review of Resident #16's Nursing Progress Note, dated 4/4/24, indicated:

-Increased paranoia noted in patient today.

-Patient vocalized frustration describing staff messing with him/her over the intercom, specifically overnight.

-The patient stated staff saying his/her name over and over again through the intercom.

Review of Resident #16's Social Services Progress Note, dated 5/1/24, indicated:

-The Resident reported feeling down at times and was prescribed Lexapro (antidepressant medication) for symptom management.

-The Resident was followed by psych services as needed.

-The Resident was last seen by psych services for one-to-one counseling on 11/3/23.

Review of Resident #16's NP Progress Note, dated 5/20/24, indicated:

-The Resident had been complaining about people playing tricks on him/her over the intercom at night.

-Nursing had completed an investigation and could not find evidence of people playing tricks on the Resident over the intercom at night.

-The Resident was quite paranoid about this and could not sleep.

-The Resident was mistrustful of staff.

-The Resident became very animated and upset when talking about the voices and said, Someone is messing with me.

-A medical work-up had been completed in the past for this same complaint and was negative.

-The NP suspected the Resident was having auditory hallucinations.

-The plan included trialing Seroquel (antipsychotic medication) 25 milligrams (mg) Q (every) HS (Hour of Sleep [night]).

Review of Resident #16's NP Progress Note, dated 6/7/24, indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 225002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Holden Rehabilitation & Nursing Center 32 Mayo Road Holden, MA 01520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 -The Resident reported voices over the intercom at night and was fearful people were trying to poison him/her. Level of Harm - Minimal harm or potential for actual harm -The Resident thought Nurses were trying to kill him/her with medications.

Residents Affected - Few -The Resident became very agitated when asked about the intercom.

-The Resident had moderate cognitive impairment with paranoia and auditory hallucinations.

-The plan included to increase the Resident's Seroquel at night from 15 mg to 50 mg and to add a dose of Seroquel 12.5 mg every morning.

-If no improvement, consult Psych.

Review of Resident #16's clinical record did not indicate any evidence that a Psychiatric Evaluation was completed as ordered by the NP on 12/14/23, until 6/11/24 (approximately six months after being ordered).

Review of Resident #16's Psychiatric Evaluation, dated 6/11/24, indicated:

-The Resident denied auditory hallucinations.

-The Resident believed staff were messing with him/her, calling his/her name through the intercom at night.

-The Resident had auditory hallucinations and paranoia.

During an interview on 2/13/25 at 7:40 A.M., Certified Nurses Aide (CNA) #2 said that she cared for Resident #16 and that the Resident sometimes experienced hallucinations where he/she talks about seeing or hearing things that are not there, such as bugs on the wall and voices through the intercom. CNA #2 said she could not recall how long Resident #16 had been having hallucinations and that the hallucinations had decreased significantly over the last month. CNA #2 said that she has not heard the Resident report any hallucinations lately.

During an interview on 2/12/25 at 1:35 P.M., the Assistant Director of Nursing (ADON) said he reviewed Resident #16's record and the most recent Behavioral Health visit provided for Resident #16 prior to the Psychiatric Evaluation on 6/11/24 was the Psychotherapy Evaluation completed on 11/3/23.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 225002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Holden Rehabilitation & Nursing Center 32 Mayo Road Holden, MA 01520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 During an interview on 2/13/25 at 8:20 A.M. with the ADON and the Director of Nursing (DON), the ADON said that the Psychotherapist who evaluated Resident #16 on 11/3/23 was no longer providing services to Level of Harm - Minimal harm or the facility since the end of 2023. The DON said it took a few months for the contracted Behavioral Health potential for actual harm Agency to find a replacement for the Psychotherapist and that staff at the facility were providing additional support for Resident #16. When the surveyor asked what support was provided for the Resident, the DON Residents Affected - Few said that she thought the SW was involved with the Resident and that the NP oversaw the Resident and initiated Seroquel for the Resident's behaviors. The DON also said that although the Psychotherapist was no longer providing services to the facility, the contracted Behavioral Health Agency did provide the facility with

a Psychiatric NP to evaluate residents at the facility. The surveyor requested evidence as to whether the facility obtained a Psychiatric Evaluation for Resident #16 after one was ordered for the Resident on 12/14/23, prior to the evaluation completed on 6/11/24. The surveyor also requested evidence of any additional Behavioral Health Support provided to the Resident between 12/14/23 and 5/20/24 when the NP assessed the Resident for auditory hallucinations.

During an interview on 2/13/25 at 9:45 A.M., the NP said that she referred Resident #16 for a Psych Eval (Psychiatric Evaluation) on 12/14/23. The NP said when Specialists, such as Psych Practitioners, assess Residents, she reviews any recommendations made and will determine whether to accept the recommendations. The NP said when Specialists complete a Consult for a resident, she has access to the Consult notes, but she does not always review the Consult notes if she is not alerted by facility staff that recommendations were made. When the surveyor asked whether the NP was aware that the Psych Evaluation had not been completed as ordered on 12/14/23, the NP said that when she made a referral, she expected that the other professionals would follow through on providing the service. The NP further said there was a period of time when the Resident's hallucinations were not occurring as much, and that the hallucinations were addressed when they increased. The NP said that even if the Psych Provider had evaluated the Resident, she did not think they would have done anything differently than what she did for the Resident.

The facility did not provide any evidence to the survey team prior to the end of the survey period relative to:

-Any communications made to obtain Psychotherapeutic Counseling for Resident #16 after the Psychotherapist's evaluation of the Resident was completed on 11/3/23 and continued therapy was recommended.

-Any Psychiatric Evaluation being obtained between 12/14/23 and 6/11/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 225002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Holden Rehabilitation & Nursing Center 32 Mayo Road Holden, MA 01520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 During a post-survey interview on 2/18/25 at 4:32 P.M., the Behavioral Health Manager said that Resident #16 was evaluated by the Psychotherapist in November 2023 and the Psychotherapist had recommended Level of Harm - Minimal harm or treatment for the Resident. The Behavioral Health Manager said that there may have been a glitch in the potential for actual harm computer system and the Resident's enrollment was not processed which resulted in the Resident not being scheduled for Psychotherapy visits. The Behavioral Health Manager said that Resident #16 was enrolled for Residents Affected - Few Psychiatric Services to be evaluated by the Psychiatric Nurse Practitioner (NP) on 12/14/23, but the evaluation was never completed. The Behavioral Health Manager said it was atypical that errors like this occurred and that she hoped this would not happen to other residents. The Behavioral Health Manager also said there was nothing in the Resident's file indicating that the Psychotherapy Services and the Psychiatric Evaluation were not to be completed for the Resident, and that Resident #16 was not evaluated by the Psychiatric NP until 6/11/24. The Behavioral Health Manager further said there was nothing in the Resident's file that indicated the facility had followed-up with the Behavioral Health Agency relative to Psychotherapy Services or the Psychiatric Evaluation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 225002