Holton Manor

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. The facility did not use the data collected on infections to apply corrective action. *Linens were not handled in a sanitary manner to prevent the spread of infection. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility did not submit for the completion of a level 2 Preadmission Screening (PASARR) for 1 (R10) of 2 sampled residents with a mental disorder and intellectual disability to see if an individual requires such level of services or whether the individual requires specialized services. * R10 did not have a completed Level 2 PASARR screen for developmental disability or to see if R10 required specialized services.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 1 (R5 and R10) of 1 sampled residents received the necessary care and services to ensure that a resident's abilities in activities of daily living (ADLs) do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable, including receiving ADL assistance to maintain grooming. * R5 requires staff assistance with ADLs and was not shaven for a couple days.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 1 (R10) of 1 sampled residents who are unable to carry out activities of daily living (ADL) receives the necessary services to maintain good grooming and personal hygiene. * R10 requires total staff assistance with ADLs, and was observed to have significant discharge matter coming from both eyes. Facility staff did not clean R10's eyes to ensure R10 maintained good personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 2 (R10 and R23) of 8 sampled residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion.* R10 was observed not having rolled up washcloths in both hands to prevent further decrease in range of motion and was not wearing shoes when up in R10's wheelchair per care plan.* R23 was observed not wearing R23's right ankle foot orthotic (AFO) to prevent further decrease in range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with a gastrostomy tube received the appropriate treatment to prevent complications of enteral feeding for 1 (R7) of 1 resident with a gastrostomy tube. R7's gastrostomy tube was not checked for placement prior to the attempt to administer medication which had the potential of causing water and medication to enter the abdominal cavity rather than the stomach.

Inspectors wroteBased on interview and record review the facility did not ensure posted nurse staffing data included the total actual hours worked by registered nurses (RN), licensed practical nurses (LPN's), and certified nurse aides (CNAs) each shift. * The facility did not document the number and actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice has the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on review of the facility policy and interview, the facility failed to ensure that seven of the 34 Skilled Nursing Facility (SNF) Certified Nurse Aides (CNA) 6, CNA9, CNA11, CNA13, CNA25, CNA29, and CNA33 reviewed for Continuing Education Requirements of 12 hours every 12-month period. Failure to ensure all CNAs receive the required ongoing education has the potential to decrease the quality of care for residents residing at the facility.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure that an Agency Certified Nurse Aide (Agency CNA) possessed the information and skill set necessary to recognize an important change in condition for one of four sample residents (Resident (R) 1) when R1 experienced chest pain during the night and the Agency CNA did not report it to the nurse on duty. Failure to report a residents change in condition has the potential to cause harm to residents.

Inspectors wroteBased on observation, interview, and record review the Facility did not provide 2 (R3 & R2) of 2 Residents who smoked and 2 (R1 & R4) of 3 Residents reviewed for falls the supervision and assistance to prevent accidents. * Staff smelled cigarette smoke in R3's room on multiple occasions. The Facility did not complete a smoke assessment or revise R3's smoking care plan to prevent further occurrences of smoking in R3's room. * The Facility identified R2 as being the only current Resident residing in the Facility who smokes. The Facility did not complete a smoking risk assessment and did not develop a smoking care plan. * R1 was observed being left alone in the bathroom. Interview with DON-B reveals R1 should not have been left alone in the bathroom. The Facility did not determine the root cause of R1's fall on 1/4/24. * R4 was observed alone in her room. [...]

Inspectors wroteBased 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. There was no update from the NP or facility and there was no appointment scheduled to see Ortho MD-F until 10/24/23 when the knee was already grossly infected.

Inspectors wroteBased on interview and record review the facility did not ensure residents have the right to voice grievances to the facility and receive a resolution to their grievance for 1 (R1) of 4 residents reviewed for grievances. R1's family voiced multiple concerns to the facility that were not documented, fully investigated and had no resolution.

Inspectors wroteBased on interview & policy review, the Facility did not ensure 1 (R2) 1 allegations of abuse were reported to the Administrator and State Survey Agency. R2 alleged that staff were rough when giving her a bed bath on 9/19/23. The allegation was not reported to the state survey agency immediately and no longer than 2 hours from the allegation.

Inspectors wroteBased on interview & record review, the Facility did not ensure that 1 resident (R2) of 1 allegation an incident of physical abuse were thoroughly investigated, and the results of the investigation reported to the State Agency. R2 alleged that staff were rough when giving her a bed bath on 9/19/23. The investigation was not thoroughly investigated as no other staff were interviewed and other residents were not interviewed to see if they had similar concerns.