Holton Manor

In the surveyor’s words

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

• Actual harm, isolatedF686May 6, 2026

  Based on observation, interview, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R37, R7) of 4 residents reviewed for pressure injuries.*R37 admitted to the facility with a stage IV pressure injury that had an abscess of bursa for wound management. R37 proceeded to develop two new pressure injuries while at the facility.*R7 did not have a comprehensive assessment of their right buttock pressure injury from 4/2/2026, when discovered, until 4/14/2026.Findings include:The facility Policy titled Pressure Injury Prevention and Management copyright 2026, documents: Policy: This facility is… […]

• Actual harm, isolatedF689May 6, 2026

  Based on observation, interview, and record review. the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (R16) of 2 residents reviewed for accidents.* R16 was not provided with the prescribed therapeutic diet and choked on food. R16 was sent to the hospital with a diagnosis of aspiration pneumonia (lung infection caused by inhaling a foreign material such as food). R16 was to be supervised intermittently while eating. R16 was observed not being intermittently supervised while eating and was left alone in the dining room for 20 minutes with no facility staff during noon meal on 5/4/2026 and 13 minutes at breakfast meal on 5/5/2026.Findings include:The facility policy titled, Therapeutic Diet Orders with no initiated, reviewed, or revised date… […]

• Actual harm, isolatedF684Oct 4, 2023

  Based on interview and record review, the facility did not ensure 1 (R1) of 4 residents reviewed for quality of care. R1 was admitted to the facility on [DATE] after a total left knee arthroplasty. After a revision arthroplasty and arthrotomy repair, R1 was readmitted to the facility on [DATE]. On 8/14/23 R1 had signs and symptoms of infection and the Orthopedic Surgeon (Ortho MD-F) requested to see R1 as soon as possible on 8/14/23 or 8/15/23 but the facility had no transportation. The facility said the in-house Nurse Practitioner (NP-G) would see R1 and update Ortho MD-F's office. […]

• No harm, potential for more than minimal, widespreadF880May 6, 2026

  Based on observation, interview, and record review, the facility did not maintain an effective infection prevention and control program or sanitary environment to help prevent the development and transmission of communicable diseases and infections potentially affecting 53 of 53 residents and 1 (R23) of 2 residents reviewed with indwelling urinary catheters. *The facility did not have a system for identifying potential infections utilizing a line list of symptomatic residents and did not report monthly infections with the calculations of rates of infection. Respiratory outbreaks did not have a summary to show an investigation of the source of transmission and the control of the infection. […]

• No harm, potential for more than minimal, widespreadF882May 6, 2026

  Based on interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 53 residents residing in the facility.The Interim Director of Nursing (IDON)-B was the facility's designated IP. IDON-B did not complete specialized infection prevention and control training. The facility also failed to designate an alternate qualified resource to oversee or the infection prevention and control program (IPCP) responsibilities of the facility. […]