Ohman Family Living at Holly

In the surveyor’s words

From the most serious findings on record at Ohman Family Living at Holly, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 21, 2025

  Based on closed medical record review, staff interview, policy review, and review of manufacturer's guidelines, the facility failed to ensure Resident #100 was transferred in a safe manner to prevent an injury during a mechanical (Hoyer) lift transfer. Actual Harm occurred on 01/31/25 at approximately 6:49 P.M. when Resident #100, who was dependent on staff for transfers, was injured during a Hoyer lift transfer when staff did not ensure Resident #100 cleared the air mattress's bolsters on the edge of the bed. As a result, the Hoyer lift tipped and struck Resident #100 on the top of the head. Resident #100 was transported to the hospital and diagnosed with a concussion and laceration to the head which required six staples to close the lacerated wound. […]

• No harm, potential for more than minimal, isolatedF842Mar 17, 2026

  Based on interviews, record review and review of facility policy, the facility failed to contain accurate information in medical records. This affected three residents (#132, #180 and #181) out of three residents reviewed for medical record accuracy. The facility census was 80.Findings include: 1. Review of the medical record for Resident #132 revealed an admission date of 12/08/25 and his diagnoses included acute respiratory failure with hypoxia (low oxygen level) and hypercapnia (increased carbon dioxide in the blood stream), sepsis, heart failure, tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe to help a patient breathe) and dependence on respiratory mechanical ventilator (a life-support treatment using a machine to assist or… […]

• No harm, potential for more than minimal, isolatedF690Feb 18, 2026

  Based on observation, interview, and record review, the facility failed to ensure timely incontinence care was provided to Resident #2. This affected one resident (#2) of three residents observed and reviewed for incontinence care. The facility census was 80.Findings include: Review of Resident #2's medical record revealed an admission date of 09/15/25. Diagnoses included spondylosis (an age-related degenerative condition) of the lumbar spine, diabetes, and high blood pressure.Review of the care plan dated 09/16/25 revealed Resident #2 had self care deficits related to weakness and limited mobility. Interventions included one staff participation with toileting. Resident #2 had bladder incontinence and required assistance with hygiene and transfers. […]

• No harm, potential for more than minimal, isolatedF880Dec 11, 2025

  Based on observation, interviews, record review and facility policy, the facility failed to ensure neutropenic guidelines and isolation were maintained for Resident #36 and the provider order was followed by staff to prevent the development and transmission of communicable diseases and infections to the immunocompromised resident. This affected one resident out of five reviewed for infection control. The census was 85.Review of the medical record for Resident #36 revealed an admission date of 10/27/25 with a diagnoses of Cauda Equina Syndrome (spinal cord injury of lower back), myeloblastic leukemia (a blood cancer), epileptic syndrome, diastolic heart failure, adult failure to thrive, depression, venous thrombosis and embolism (blood clots), and depression.Review of the physician's orders… […]