Holt Senior Care and Rehab Center

In the surveyor’s words

From the most serious findings on record at Holt Senior Care and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 9, 2026

  Based on observation, interview and record review the facility failed to implement care planned interventions to prevent falls in 1 of 3 sampled residents (Resident #69) assessed for falls, resulting in repeated falls during staff assisted transfers and the potential for continued falls and/or serious injury. Findings include:Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date of 1/22/26, reflected R69 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral infarction with hemiparesis affecting left non-dominant side(left side paralyzed , vascular dementia, left above the knee amputation, atrial fibrillation(heart arrythmia with use of blood thinners), cognitive communication deficit, and major depressive disorder… […]

• No harm, potential for more than minimal, patternF880Jan 15, 2025

  Based on observation, interview and record review, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized for contact precaution and ensure hand hygiene was performed for four (Resident #22, 26, 52, and 57) of reviewed for contact precautions. Findings include: On 1/13/25 at 10:34 AM, a contact precaution sign was observed outside of the room of Resident #22 (R22) and Resident #57 (R57). The contact precaution sign indicated that hand washing prior to entry of the room, as well as donning a gown and gloves (PPE) was necessary prior to entering the room. On 1/13/25 at 10:37 AM, a contact precaution sign was observed outside of the room of Resident #26 (R26) and Resident #52 (R52). […]

• No harm, potential for more than minimal, patternF689Sep 23, 2022

  This citation includes intake MI 8592. Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned and non-care-planned interventions, and 3.) ensure that those interventions were functional and in place in 4 of 6 sampled residents (R19, R28, R30, and R37) reviewed for falls, resulting in repeat falls and R28 unwitnessed fall from elevated bed resulting in left lower leg fracture, deep tissue injury, decline and later death. […]

• No harm, potential for more than minimal, patternF880Sep 23, 2022

  Based on observation, interviews, and record review the facility failed to establish and maintain an infection prevention, monitoring and control program while residents are in quarantine with Covid, resulting the potential for the spread of microorganisms when staff did not wear personal protective equipment while assisting residents. Staff did not perform hand hygiene before or after care, did not change out gowns, mask or clean goggles before leaving the residents room, resulting in the potential for the spread of infections to (R35, R39, R49, R56, R224) and up to 71 residents who resided at the facility. During observation on 09/23/22 at 08:50 AM, Staff were observed entering and exiting the residents' rooms on quarantine without wiping goggles off or changing out mask. […]

• No harm, potential for more than minimal, isolatedF641Apr 9, 2026

  Based on observation, interview and record review, the facility failed to ensure accurate coding of a Minimum Data Set (MDS) assessment for one (R80) of 19 reviewed.Findings include: Review of the medical record reflected R80 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included end stage renal disease and dependence on renal dialysis. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/3/25, reflected R80 received dialysis. The Quarterly MDS, with an ARD of 1/27/26, reflected R80 was not coded as receiving dialysis. On 04/09/2026 at 11:40 AM, R80 was observed lying in bed. A Physician's Order, with a revision date of 4/16/25, reflected R80's scheduled dialysis days were Monday, Wednesday, Friday and as needed. […]