Holzer Senior Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686May 8, 2025

  Based on observation, record review, review of wound notes, facility policy review review and interview, the facility failed to assess, develop, and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers and ensure interventions were in place as ordered to prevent new or worsening pressure injuries for Resident #8 and #34. Actual Harm occurred on 04/17/25 when it was discovered that Resident #8, who was determined to be at risk for skin breakdown with no pressure ulcers upon admission, was assessed as cognitively impaired, incontinent, and required moderate (staff) assistance with bed mobility, developed an unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may… […]

• Actual harm, isolatedF686Oct 18, 2021

  Based on observation, record review, facility policy and procedure review and interview the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #10. Actual harm occurred on 10/07/21 when Resident #10, who was severely cognitively impaired was identified to have a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to the ball of his left foot. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. […]

• Actual harm, isolatedF688Oct 18, 2021

  Based on observation, record review, facility policy and procedure review and interview the facility failed to provide adequate and necessary care and services to prevent the development of hand contractures for two residents (#5 and #25). Actual harm occurred when Resident #25 who was severely cognitively impaired was not provided range of motion services or the application of splint/ orthotic devices resulting in the development of bilateral hand contractures. Actual Harm also occurred for Resident #5 when the facility failed to provide range of motion and/or hand roll/splinting care for the resident's left hand to prevent a decline in range of motion and development of a contracture to the hand. […]

• No harm, potential for more than minimal, widespreadF880Oct 18, 2021

  Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure appropriate personal protective equipment (PPE) was worn by nursing staff when providing direct care to Resident #340, who was on droplet precautions for a 14 day quarantine period for COVID-19 following a recent admission. They also failed to ensure nursing staff properly disinfected their face shields when leaving the resident's room before moving on to provide care to other residents to prevent the potential spread of COVID-19. This had the potential to affect all 37 residents residing in the facility. […]

• No harm, potential for more than minimal, patternF644May 8, 2025

  Based on record review and interview, the facility failed to ensure Pre-Admission Assessment/Resident Reviews (PASRRs) were completed accurately to reflect diagnoses of serious mental illness. This affected four (#7, #12, #13, and #28) of four residents reviewed for PASRRs. The facility census was 40. Findings include: 1. Record review revealed Resident #7 admitted to the facility on [DATE] with diagnoses including cerebral infarction, unspecified psychosis, delusional disorders, major depression, and anxiety disorder. Review of a care plan revised on 10/31/18 revealed Resident #7 had depression related to diagnosis and signs and symptoms including false accusations, anger with shaking, sad facial expressions, tearfulness, and agitation. […]