Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holt Senior Care And Rehab Center during CMS and state inspections, most recent first.
A resident with CVA-related hemiparesis, an AKA, dementia, and dependence for all transfers had repeated falls during staff-assisted transfers because staff did not follow the care plan. Records and interviews showed transfers done with one staff member instead of two, missing or unused gait belts, and wheelchair brakes not secured, resulting in the resident being lowered or falling to the floor multiple times. The DON, CNAs, and the resident’s daughter all confirmed the resident required two-person assist with a gait belt and that the same transfer precautions were not consistently followed.
Inaccurate MDS coding for dialysis. A resident with ESRD and dependence on renal dialysis had an Annual MDS that coded dialysis, but a later Quarterly MDS did not. The chart included a physician order for dialysis on M/W/F as needed, and the MDS Nurse acknowledged the Quarterly MDS should have been coded for dialysis.
A resident’s care plan was not updated after a code status change from full code by default to DNR, and another resident with CVA, hemiparesis, an AKA, and other conditions had repeated falls during staff-assisted transfers. Records and staff interviews showed the resident’s care plan required 2-person assist, a gait belt, locked wheelchair brakes, and staff supervision, but staff repeatedly used 1-person transfers or omitted the gait belt and other required interventions, resulting in falls and injuries.
Incomplete Hospice Documentation in Resident Record: A resident with cirrhosis, kidney failure, HF, DM, anxiety, and depression had an EMR that lacked Hospice visit notes for months, despite ongoing Hospice involvement and pain management concerns. The resident reported that Hospice and facility staff often disagreed about pain medication directions, while the CCC, Medical Records, and DON all verified that the most recent Hospice documents in the EMR and Hospice binder were outdated and that current Hospice recommendations for pain control could not be determined.
Failure to Document and Administer Ordered Antibiotic: A resident with Parkinson's disease, DM, and PVD was treated for cellulitis of the right lower extremity, but cephalexin doses were repeatedly not documented as administered on the MAR. The physician ordered cephalexin 500 mg TID, yet multiple scheduled doses were missing across the treatment period, and the facility could not verify that all doses were actually given.
Unsafe Transport of Portable Oxygen Tank: An LPN was observed carrying a portable oxygen tank down Hall C without an oxygen transport cart, then later wheeling the tank in a cart through both C Halls and into a resident room while residents and staff were present. The LPN stated she had not been educated on safe transport of portable oxygen tanks and did not know the tank could not be carried; the CC and DON stated portable oxygen tanks should only be transported in a wheeled oxygen cart, and the facility policy required oxygen cylinders to be secured in an appropriate holder.
The facility failed to ensure proper use of PPE and hand hygiene for residents under contact precautions due to gastroenteritis. Staff members entered and exited rooms without performing hand hygiene or donning required PPE, despite acknowledging the need for such precautions. The infection control program was not effectively implemented, leading to repeated protocol violations.
A facility failed to timely complete a Significant Change in Status Assessment (SCSA) for a resident admitted to hospice care. The resident, with chronic obstructive pulmonary disease and chronic kidney disease, was signed onto hospice on December 16, but the SCSA MDS was not initiated until January 13 and was incomplete by January 14. The MDS Nurse acknowledged the delay but offered no explanation.
The facility failed to transmit MDS assessments to CMS within the required timeframe for two residents. One resident, admitted with diabetes and renal dialysis dependence, and another, admitted after surgery for neoplasm, had their MDS assessments completed but not transmitted. MDS Nurse D acknowledged the oversight, noting the facility's 14-day transmission requirement.
A facility failed to ensure accurate coding on an MDS assessment for a resident who was admitted with a wedge compression fracture. The MDS incorrectly indicated the resident was discharged to a hospital, while records and an interview with the MDS Nurse confirmed the resident was discharged home.
A facility failed to ensure a PASARR Level II evaluation was completed for a resident with mental illness before admission. The resident, diagnosed with morbid obesity and bipolar disorder, was receiving psychotropic medication. Despite this, there was no documentation of the CMH's awareness of the admission, and the necessary evaluation was not completed. Staff interviews revealed confusion and lack of responsibility for tracking and completing PASARR documentation, leading to a significant delay in the process.
A resident in an LTC facility experienced delayed treatment due to the facility's failure to provide timely laboratory services and report results. The resident, with a history of deep vein thrombosis and other conditions, had issues with Coumadin dosing regulation. PT/INR tests were not conducted as ordered, leading to unstable medication levels. The facility's recent change in lab service provider and restricted lab access contributed to these delays.
Repeated failure to follow transfer precautions for a high-fall-risk resident
Penalty
Summary
The facility failed to implement care planned interventions to prevent falls for a resident with significant mobility impairment and a history of repeated falls during staff-assisted transfers. The resident was a female with diagnoses including cerebral infarction with left hemiparesis, vascular dementia, left above-the-knee amputation, atrial fibrillation with blood thinner use, cognitive communication deficit, and major depressive disorder. Her MDS reflected she was dependent on staff for bed mobility and all transfers, and the fall care plan required two-person assist for transfers, use of a gait belt, locked wheelchair brakes, non-skid footwear, and staff presence in the restroom or on the toilet. Review of the resident’s records showed multiple falls during transfers in which staff did not follow the care plan. On one occasion, a CNA transferred the resident from bed to wheelchair without locking the wheelchair brakes, and the wheelchair slipped out from under her, causing her to fall and sustain a skin tear. On another occasion, the resident was transferred from bed to wheelchair and slipped out of the CNA’s arms. A later incident documented that the wheelchair moved backward during transfer even though the brakes had been applied, and the resident was lowered to the floor with an abrasion to her back. Another fall occurred when the resident was found on the floor near the toilet and wheelchair, and staff reported she had been lowered to the floor. The resident’s fall assessment and incident records reflected that she remained at risk for falls and required two-person extensive assistance with transfers, yet the incident reports showed repeated failures to follow the Kardex and care plan. The reports identified transfers performed with one staff member instead of two, and in some cases no gait belt was used because staff could not find one. The facility’s incident/accident reports also did not appear complete and did not include staff names for the involved employees. Interviews with CNAs, an LPN, the DON, and the resident’s daughter confirmed that staff were aware the resident required two-person assist with a gait belt, but transfers continued to be done incorrectly and the resident had been dropped several times during staff-assisted transfers.
Inaccurate MDS Coding for Dialysis
Penalty
Summary
The facility failed to ensure accurate coding of an MDS assessment for one resident, R80, out of 19 reviewed. R80 was admitted to the facility and later readmitted with diagnoses including end stage renal disease and dependence on renal dialysis. The Annual MDS with an ARD of 11/3/25 reflected that R80 received dialysis, but the Quarterly MDS with an ARD of 1/27/26 did not code R80 as receiving dialysis. The medical record also included a physician's order, revised 4/16/25, showing that R80's scheduled dialysis days were Monday, Wednesday, and Friday, as needed. During observation on 04/09/2026, R80 was lying in bed. In interview on 04/08/2026, the MDS Nurse acknowledged that the Quarterly MDS should have been coded for dialysis.
Care Plans Not Updated for Code Status Change and Transfer Safety Needs
Penalty
Summary
The facility failed to ensure comprehensive care plans were accurate and implemented for two residents. One resident was admitted with a code status of full code by default, later had multiple Code Status Forms completed, and was eventually changed to DNR status. The resident’s care plan contained a focus on advanced directives and stated that CPR was by default, but the care plan was not updated when the resident’s code status changed to DNR. Staff interviews reflected that Social Services was responsible for updating the care plan when the code status changed, but the care plan remained unchanged after the DNR decision. Another resident had diagnoses including cerebral infarction with left-sided hemiparesis, vascular dementia, left above-the-knee amputation, atrial fibrillation, cognitive communication deficit, and major depressive disorder. The resident’s MDS reflected dependence on staff for bed mobility and all transfers. The resident was observed sitting in a wheelchair and reported being unable to use the left side of the body and having had several falls at the facility during staff-assisted transfers. The resident also reported uncertainty about injuries from those falls. Record review showed multiple fall incidents during staff-assisted transfers. Progress notes documented falls when the resident was being transferred from bed to wheelchair or during other transfers, including incidents where the wheelchair was not locked, staff used one-person assist instead of two-person assist, and a gait belt was not used. The resident sustained injuries including a skin tear, abrasion, and bruising. The fall care plan identified the resident as needing two-person assist for transfers, use of a gait belt, locked wheelchair brakes, non-skid footwear, and staff presence in the restroom, but incident reports and interviews showed staff repeatedly did not follow those care planned interventions during transfers.
Incomplete Hospice Documentation in Resident Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident whose chart was reviewed. The resident was a female admitted with diagnoses including cirrhosis of the liver, kidney failure, heart failure, diabetes, anxiety, and depression. Her MDS reflected a BIM score of 15, indicating she was cognitively intact and required staff assistance with dressing, hygiene, bathing, transfers, and toileting. During observation, she was in bed with a guest at bedside and reported that she had been receiving Hospice services since December and that Hospice and facility staff often did not agree about pain medication directions, stating that they did not seem to speak to each other. Review of the resident’s progress note reflected a Hospice collaboration meeting in which her current condition and Hospice services were reviewed, and it documented that she continued to express pain, declined pain medication because it made her sleepy, and continued to take Ativan as needed for anxiety. However, review of the EMR from 12/12/25 through 4/8/26 showed no Hospice visit notes since 1/14/26, and staff were unable to determine Hospice recommendations for pain control changes. The CCC verified that Hospice notes were not in the EMR or Hospice binder since 1/14/26, Medical Records stated the most recent Hospice documents were from 1/14/26 and that obtaining Hospice visit notes was not their responsibility, and the DON stated Hospice visit notes were expected to be added to the EMR within one month and could not locate any notes since 1/14/26.
Failure to Document and Administer Ordered Antibiotic
Penalty
Summary
The facility failed to ensure cephalexin was administered as ordered for one resident with Parkinson's disease, diabetes, and peripheral vascular disease who was cognitively intact on the MDS. The resident was admitted with cellulitis of the right lower extremity and was observed sitting in a wheelchair with the right leg wrapped in a bandage while reporting she was receiving an antibiotic for the condition. The physician ordered cephalexin 500 mg three times daily for 7 days, but the MAR did not show administration for multiple scheduled doses, including doses on 3/4/26, 3/6/26, 3/7/26, and 3/10/26. The resident later had another order for cephalexin after the nurse documented that the last dose of antibiotic had been given and the right lower extremity remained erythematous and warm to touch. The MAR again did not document several scheduled doses as administered, including doses on 3/11/26, 3/12/26, and 3/14/26. The facility could document removal of one dose from the cart and pharmacy deliveries totaling 42 capsules, plus two capsules from backup supply, but could not provide documentation that the other doses were actually administered. The MAR indicated 9 of the 42 doses from the treatment period were not documented as administered as ordered.
Unsafe Transport of Portable Oxygen Tank
Penalty
Summary
The facility failed to safely transport a portable oxygen tank when an LPN was observed carrying the tank down Hall C, past the Hall C nurse station and partway down the hall to the oxygen storage closet without using an oxygen transport cart. The LPN then exited the oxygen storage room with the portable oxygen tank in a transport cart and wheeled the cart down both C Halls and into room C23 while several residents and staff were present in the area. During interview, the LPN reported she had worked at the facility for over two years and had been a nurse for over 30 years. She stated she had not received education on safe transport of portable oxygen tanks before the observation and did not know that the tank could not be carried. The Clinical Care Coordinator for Hall C stated portable oxygen tanks should only be transported in a wheeled oxygen cart, and the DON stated oxygen tanks should be transported in oxygen carts because if dropped they could become like a missile. The facility policy on oxygen administration and safety stated oxygen cylinders should be secured in an appropriate holder.
Failure to Adhere to Contact Precaution Protocols
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was utilized and hand hygiene was performed for residents under contact precautions. Observations revealed that staff members entered and exited rooms of residents with gastroenteritis without performing hand hygiene or donning the required PPE, such as gowns and gloves. Specific instances included a staff member entering a room wearing gloves without hand hygiene, changing trash liners, sweeping, and mopping without changing gloves or performing hand hygiene. Another staff member entered multiple rooms without performing hand hygiene or wearing PPE, despite acknowledging the requirement for such precautions. Additionally, a Certified Nursing Assistant (CNA) was observed delivering items to a resident's room without performing hand hygiene or wearing proper PPE, and was unaware of the need for contact precautions. Interviews with staff confirmed the requirement for hand hygiene and PPE when entering contact precaution rooms, yet these protocols were not followed. The infection control program overseen by a Registered Nurse (RN) was not effectively implemented, as evidenced by the repeated failure to adhere to contact precaution protocols for residents with gastroenteritis symptoms.
Delayed SCSA MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) in a timely manner for a resident who was admitted with chronic obstructive pulmonary disease and chronic kidney disease. The resident was signed onto hospice care on December 16, 2024, as indicated by the physician's order and hospice notes. However, the SCSA Minimum Data Set (MDS) was not initiated until January 13, 2025, and remained incomplete as of January 14, 2025. During an interview, the MDS Nurse acknowledged that the SCSA MDS should have been started in December when the resident was admitted to hospice care but did not provide an explanation for the delay.
Failure to Timely Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for two residents. Resident #49 was admitted with diagnoses including diabetes and dependence on renal dialysis. Their MDS assessment, with an Assessment Reference Date (ARD) of 8/31/24, was completed on 9/11/24 but was not transmitted to CMS. Similarly, Resident #89, admitted with diagnoses including aftercare following surgery for neoplasm, had an MDS assessment with an ARD of 8/30/24, completed on 9/11/24, which also was not transmitted to CMS. In an interview, MDS Nurse D stated that the facility had 14 days from the date of MDS completion to transmit the data to CMS. However, the nurse acknowledged that the discharge return not anticipated MDS assessments for both residents had not been transmitted, indicating a failure to meet the regulatory requirement.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure accurate coding on a Minimum Data Set (MDS) assessment for a resident. The resident was admitted to the facility with a diagnosis that included a wedge compression fracture of the second thoracic vertebra. The discharge return not anticipated MDS, with an Assessment Reference Date (ARD) of December 9, 2024, incorrectly reflected that the resident was discharged to a short-term hospital. However, a progress note for the same date indicated that the resident was discharged home. In an interview, the MDS Nurse confirmed that the resident was discharged home and acknowledged the coding error on the MDS.
Failure to Complete PASARR Level II Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a Level II OBRA evaluation prior to the admission of a resident with mental illness. The resident, who was admitted with diagnoses including morbid obesity and bipolar disorder, was found to have a mental illness diagnosis and was receiving psychotropic medication, including an anti-psychotic. Despite this, there was no documentation that the CMH was aware of the resident's admission six months prior, and the necessary Level II evaluation was not completed. Interviews with facility staff revealed a lack of clarity and responsibility regarding the tracking and completion of the necessary PASARR documentation. The social worker reported that the resident had a Level II completed by another county, but it was not present in the medical record, and there was confusion about the status. The MDS Nurse stated she was not responsible for tracking the 3877/3878 forms and only completed them when notified by the Social Work Department. The social worker also indicated that the resident had stayed beyond the 30-day exemption at another facility, and the Level II evaluation was started but not completed by the CMH in the other county. The facility did not complete a second 3877 screen until four months after the resident's admission, with no explanation provided for the delay.
Delayed Laboratory Services and Reporting in LTC Facility
Penalty
Summary
The facility failed to provide timely laboratory services and report laboratory results for a resident, leading to delayed treatment and impaired coordination of care. The resident, a female with a history of deep vein thrombosis, hypertension, pelvic fracture, dementia, chronic kidney disease, anxiety, and depression, was admitted for rehabilitation. Her husband expressed concerns about swelling in her feet, symptoms of a urinary tract infection, and issues with regulating her Coumadin dosing. Despite assurances from the physician, these concerns were not addressed promptly, resulting in delayed intervention. The resident's medical records showed inconsistencies in the monitoring and administration of Coumadin, a blood thinner. There were several instances where the PT/INR tests, which measure blood clotting time, were not conducted as ordered by the physician. For example, a PT/INR test ordered for August 12 was not completed until August 14, and another test ordered for August 19 was not conducted until August 21. These delays in testing and reporting results contributed to the resident's unstable Coumadin levels, which fluctuated between sub-therapeutic and elevated levels without timely medication adjustments. Interviews with facility staff revealed that the facility had recently changed its laboratory service provider to American Health Associates, which only visited the facility on specific days. This change, along with issues related to lab staffing and communication, contributed to the delays in obtaining and reporting lab results. The facility's inability to use local hospital labs and the restriction on staff drawing labs for external processing further compounded the problem. Despite these challenges, the facility had not initiated a performance improvement project to address the lab service issues, although the topic had been discussed in Quality Assurance and Performance Improvement meetings.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 134 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aria Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Capital Area | 3.2 mi | ★★★★★ | 5 | 0 |
| Dimondale Nursing Care Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Campus Area | 7 mi | ★★★★★ | 11 | 0 |
| Ingham County Medical Care Facility | 7.6 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Holt Senior Care And Rehab Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.