Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 1 | 0 |
| Ingham County Medical Care Facility | 7.6 mi | — | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.