All citations for Holden Manor Health & Rehabilitation

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Holden Manor Health & Rehabilitation

Last standard health inspection on record

August 2, 2024

This is more than 2 years ago. Newer inspection results may not be on record yet, so the results below may not describe the home today. Ask the home for its most recent inspection report.

Showing 1 to 25 of 28 citations

No harm, with potential for more than minimal harm
Develop and maintain an Emergency Preparedness Program (EP).
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of August 2, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (September 15, 2024).
No harm, with potential for more than minimal harm
Establish policies and procedures including evacuation.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0020, Emergency Preparedness Deficiencies. Inspection of August 2, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (September 15, 2024).
No harm, with potential for more than minimal harm
Establish staff and initial training requirements.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of August 2, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (September 15, 2024).
No harm, with potential for more than minimal harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0354, Smoke Deficiencies. Inspection of August 2, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (September 15, 2024).
No harm, with potential for more than minimal harm
Meet requirements for the installation and maintenance of electrical systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0911, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 2, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (September 15, 2024).
No harm, with potential for more than minimal harm
Address subsistence needs for staff and patients.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0015, Emergency Preparedness Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Provide primary/alternate means for communication.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0032, Emergency Preparedness Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Use approved construction type or materials.
Widespread (many residents). CMS level F.
Fire safety citation K-0161, Construction Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Widespread (many residents). CMS level F.
Fire safety citation K-0211, Egress Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Widespread (many residents). CMS level F.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
Widespread (many residents). CMS level F.
Fire safety citation K-0324, Smoke Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
A waiver was granted (March 31, 2023).
No harm, with potential for more than minimal harm
Install a fire alarm system that can be heard throughout the facility.
Widespread (many residents). CMS level F.
Fire safety citation K-0341, Smoke Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Widespread (many residents). CMS level F.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Widespread (many residents). CMS level F.
Fire safety citation K-0901, Electrical Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Widespread (many residents). CMS level F.
Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
Widespread (many residents). CMS level F.
Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of August 2, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (September 15, 2024).
No harm, with potential for more than minimal harm
Provide at least two remote exits on each floor or fire section of the building.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0252, Egress Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Meet other general requirements that are deficient.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0300, Egress Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).
No harm, with potential for more than minimal harm
Meet requirements for the use of electrical equipment.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0919, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 21, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.