Cycle 1
Health 2025-01-15 · Fire 2025-01-15
5 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Holt, MI
Holt Senior Care and Rehab Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5091 Willoughby Road, Holt, MI
(517) 694-2144
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexcare Health Systems
Operator or chain grouping
Approved since
1976-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing
LPN hours / resident day
0.70
Licensed practical nurse staffing
Aide hours / resident day
2.41
Nurse aide staffing
Weekend hours
3.56
Weekend nurse staffing
RN turnover
16%
Annual RN turnover
Total nurse turnover
28%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
95.0%
4 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
3.1%
2.8 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.1%
3.7 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.5%
1.5 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
19.6%
3.7 pts better
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
16.5%
4.7 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.7% |
13.9%
7.2 pts better
|
16.3%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
11.7%
7.7 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.4% |
20.4%
6 pts better
|
19.8%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
5.6%
3.9 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
82.8%
9.5 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
11.5%
4.9 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
79.5%
11.1 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
24.2%
5.1 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-09-23 · Fire 2022-09-23
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-15
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-02-04
F · Potential for more than minimal harm
2025-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-04
F · Potential for more than minimal harm
2025-01-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-04
F · Potential for more than minimal harm
2025-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-04
F · Potential for more than minimal harm
2023-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-06
F · Potential for more than minimal harm
2023-12-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-12-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-12-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-11
F · Potential for more than minimal harm
2022-09-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-09-23
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-10-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-15
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-15
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-04
D · Potential for more than minimal harm
2024-08-22
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-09-05
D · Potential for more than minimal harm
2023-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-11
E · Potential for more than minimal harm
2022-09-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-10-28
Penalties and ownership
What sits behind the stars
Ownership
Nexcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Branscum, James
5% Or Greater Indirect Ownership Interest · Individual
Eisenberg, Leo
5% Or Greater Indirect Ownership Interest · Individual
Nexcare Health Systems, LLC
Operational/Managerial Control · Organization
Patrick, Marie
W-2 Managing Employee · Individual
Perry, Michael
Operational/Managerial Control · Individual
Robin Eisenberg 2014 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sangster, Todd
Corporate Officer · Individual
Wronski, Frank
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Aria Nursing and Rehabilitation
Lansing, MI
1-star overall rating with 1-star inspections with $75,834 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Medilodge of Capital Area
Lansing, MI
3-star overall rating with 2-star inspections with $69,933 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Dimondale Nursing Care Center
Dimondale, MI
2-star overall rating with 2-star inspections with $54,280 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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