Holton Health Care Center

In the surveyor’s words

From the most serious findings on record at Holton Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 19, 2024

  The facility identified a census of 28 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 received care consistent with the standards of practice when staff failed to report abnormal x-ray findings and obtain physician involvement for treatment. On 06/04/24, R1 had a fall in the facility's van. On 06/06/24, R1 complained of right shoulder pain and staff obtained an order for an x-ray. The x-ray showed a medial subluxation (dislocation) of R1's right glenohumeral joint (ball and socket joint at the shoulder). Staff failed to notify R1's physician of the results. […]

• Immediate jeopardy, isolatedF699Jan 29, 2024

  The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to provide trauma-informed care for Resident (R) 17 who had an extensive history of trauma. On [DATE], the facility performed a social services assessment on R17 which revealed an extensive history of traumatic relationships, experience with disaster, profound feelings of helplessness, history of serious accidents and/or injuries and a history of abuse and sexual harassment. Despite this information, the facility did not develop a plan of care which identified and addressed triggers in order to prevent recurring traumatization. […]

• Immediate jeopardy, isolatedF742Jan 29, 2024

  The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to implement immediate protective measures when Resident (R) 17 verbalized suicidal intent and/or ideations. The facility further failed to assess R17's underlying causes of distress and failed to implement person-centered interventions to address the distress and prevent recurring or ongoing distress. On [DATE] R17 told Activity Staff Z about her history of traumatization, previous suicide attempts, and her feelings of wanting to shoot herself or jump to her death. R17 cried and shared the reasons she felt this way with Activity Staff Z. Activity Staff Z told Administrative Staff A. […]

• Immediate jeopardy, isolatedF609Oct 16, 2023

  The facility identified a census of 25 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure staff immediately reported allegations of abuse to the facility administrator. On 10/07/23 at approximately 04:45 PM Dietary Staff (DS) CC heard a loud verbal interaction between Administrative Nurse D and Resident (R)1 which DS CC perceived as verbal abuse. DS CC reported the alleged verbal abuse to DS BB on the evening of 10/08/23 and DS BB reported the event to Administrative Staff A on 10/09/23 at approximately 06:10 AM, almost two days later. […]

• Immediate jeopardy, isolatedF760Jun 8, 2022

  The facility identified a census of 31 residents. The sample included three residents reviewed for medication administration. Based on record review, observations, and interviews, the facility failed to prevent a significant medication error when Licensed Nurse (LN) G incorrectly administered insulin (hormone that lowers the level of glucose in the blood) to Resident (R) 1, a newly admitted resident who did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She then entered R1's room, obtained her blood sugar (BS), then administered R2's insulin to R1 in error. As a result, R1 developed [CONDITION(S)] (low blood sugar) despite multiple administrations of oral glucose. […]