Holton Manor

Inspection findings

1. May 6, 2026 Health · 19 findings
   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0676 Quality of Life and Care Deficiencies

     Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 30, 2026 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jun 25, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected May 30, 2026 · CMS health inspection

   • Serious Scope/severity G

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 25, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0925 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that sources of ignition are removed from patients receiving respiratory therapy.

     Corrected May 30, 2026 · CMS fire safety

2. Mar 20, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0726 Nursing and Physician Services Deficiencies

     Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

     Corrected Apr 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0947 Nursing and Physician Services Deficiencies

     Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

     Corrected Apr 20, 2025 · CMS health inspection

3. Nov 27, 2024 Fire Safety · 4 findings
   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Dec 2, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Dec 3, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Feb 10, 2025 · CMS fire safety

4. Feb 1, 2024 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 23, 2024 · CMS health inspection

5. Oct 4, 2023 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Nov 2, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 2, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Nov 2, 2023 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Nov 2, 2023 · CMS health inspection

6. Aug 24, 2023 Fire Safety · 4 findings
   • Not serious Scope/severity E

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Aug 30, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 30, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Sep 8, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Aug 28, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• DUPONT, LORI — corporate officer, NOT APPLICABLE, since 01/25/2016
• DUPONT, LORI — operational/managerial control, NOT APPLICABLE, since 01/01/2015
• GEHLER, MIRIAM — corporate director, NOT APPLICABLE, since 03/14/2011
• GEHLER, MIRIAM — operational/managerial control, NOT APPLICABLE, since 05/01/2016
• GERLACH, KERI — operational/managerial control, NOT APPLICABLE, since 01/01/2019
• GERLACH, KERI — corporate director, NOT APPLICABLE, since 09/24/2019
• KERWIN, ANDREW — operational/managerial control, NOT APPLICABLE, since 01/01/2016
• KERWIN, ANDREW — corporate officer, NOT APPLICABLE, since 06/26/2009
• KERWIN, ANDREW — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 04/08/2026
• KUMAR, RAJEEV SHIVA — operational/managerial control, NOT APPLICABLE, since 04/24/2012
• KUMAR, RAJEEV SHIVA — corporate director, NOT APPLICABLE, since 04/24/2012
• LYNN, NICHOLAS — corporate director, NOT APPLICABLE, since 03/14/2011
• LYNN, NICHOLAS — operational/managerial control, NOT APPLICABLE, since 03/14/2011
• SARASIN, ALYSSA — adp of the snf, NOT APPLICABLE, since 10/01/2023
• SHERMAN, STEPHANIE — adp of the snf, NOT APPLICABLE, since 08/12/2012
• SHERMAN, STEPHANIE — operational/managerial control, NOT APPLICABLE, since 08/12/2012
• SIEBEL, ROBERT — operational/managerial control, NOT APPLICABLE, since 10/01/1999
• SIEBEL, ROBERT — adp of the snf, NOT APPLICABLE, since 10/01/1999
• CARRIAGE HEALTHCARE COMPANIES INC — operational/managerial control, NOT APPLICABLE, since 02/15/2001
• HBT IT LLC — adp of the snf, NOT APPLICABLE, since 07/01/2024
• JT AND ASSOCIATES LLC — adp of the snf, NOT APPLICABLE, since 01/01/2010
• OAK MEDICAL SC — adp of the snf, NOT APPLICABLE, since 01/14/2019
• PARTNERS IN WEALTH MANAGEMENT, INC — adp of the snf, NOT APPLICABLE, since 01/01/2024
• PINION, LLC — adp of the snf, NOT APPLICABLE, since 01/01/1995
• REHAB SOLUTIONS GROUP, LLC — adp of the snf, NOT APPLICABLE, since 01/01/2024
• TWOMAGNETS LLC — adp of the snf, NOT APPLICABLE, since 01/01/2022