Holland Center for Rehabilitation and Nursing

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to ensure a complete and thorough investigation was completed for allegations of potential abuse and neglect for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to accurately update the State Survey Agency on the outcome of an investigation for one of two residents reviewed (Resident R56).

Inspectors wroteBased on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure safety interventions for falls were in place for one of three residents reviewed for falls (Resident R7).

Inspectors wroteBased on review of clinical records and interview with staff, it was determined the facility failed to ensure pain medication was administered in accordance with the physician's order for two of two residents reviewed for pain management. (Resident R20 and Resident R27)Findings Include:Review of Resident R20's clinical record revealed Resident R20 was admitted to the facility on [DATE] with a diagnosis of cirrhosis of liver (condition where the liver becomes scarred and damaged over time, making it harder for the liver to work properly), lack of coordination, and rheumatoid arthritis (long-term disease where the body's immune system attacks the joints, causing pain, swelling, stiffness, and sometimes joint damage). [...]

Inspectors wroteBased on review of clinical records, facility policy, and interview with staff , it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of two residents sampled for post-traumatic stress disorder (PTSD). (Resident R4 and R18).

Inspectors wroteBased on observations, review of clinical records, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure skilled competencies were completed for three of six nursing personnel files reviewed (Employee E5, Employee E6 and Employee E7).

Inspectors wroteBased on interviews with staff, and clinical record reviews, it was determined that the facility failed to ensure that clinical records were accurately documented for 4 of four residents reviewed. (Resident R20, Resident R27, Resident R34, Resident R61)

Inspectors wroteBased on review of information submitted by the facility, hospital records, clinical records, policy and procedures, and interviews with residents and staff, it was determined the facility failed to ensure resident received adequate assistance and supervision with assistive devices to prevent accidents for one of eight residents reviewed for falls and functional abilities. Resident CL1 fell during an attempted improper transfer with staff causing the resident actual harm. (Resident CL1).

Inspectors wroteBased on observations of the physical environment, interviews with staff and reviews of clinical records, hospital records and policies and procedures, it was determined that the facility failed to provide adequate supervision to prevent an unauthorized leave from the nursing unit resulting in a resident elopement from one of five residents reviewed. (Resident Cl1)

Inspectors wroteBased on a review of facility policies and procedures, employee personnel records, and staff interviews, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history for three of five newly hired employees reviewed. (Employees E8, E9, E10)

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that allegations of abuse and neglect was reported immediately to the Pennsylvania Department of Health for one of four residents reviewed. (Resident R143) Findings Include: A review of the Facility Policy titled Abuse Prevention Program revised November 30, 2022, revealed our residents but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental and sexual or physical abuse, physical or chemical restrains to required to treat resident's symptoms. [...]

Inspectors wroteBased on review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of two clinical records reviewed (Resident R140). Findings Include: Review of facility policy, Care Plan, Comprehensive Person-Centered revised March 2022, revealed, A comprehensive, personal -centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident 140's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of severe protein-calorie malnutrition, anorexia (eating disorder that involves severe calorie restriction), depression (loss of interest in pleasurable activities), muscle weakness. On May 13, 2025, at 12:13 p.m. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for three of twelve residents reviewed (Residents R29, R4 and R188 ).

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for two of 12 residents reviewed (Residents R4, R29).

Inspectors wroteBased on a review of employee personnel records and staff interviews, it was determined that the facility failed to complete performance reviews for nurse aides in one out of the two employee personnel records reviewed. (Employee E12)

Inspectors wroteBased on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to to ensure that nursing staff was informed of a resident with a diagnosis of PTSD (Post traumatic Stress Disorder) to ensure treatment and services for one of one resident review with PTSD. (Resident R4)

Inspectors wroteBased on review of clinical records and interviews with staff, it was determined the facility failed to acquire, receive and administer medications to a newly admitted resident for one of 12 resident records reviewed (Resident 190).

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, and facility policy it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Residents R29), and failed to administer medications in a timely manner, and as ordered by the physician for one of 12 resident records reviewed (Resident R188).

Inspectors wroteBased on a review of the observations, and an interview with residents and staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in two of two nursing floors. (First Floor and Second Floor.

Inspectors wroteBased on observation, clinical record review, and interviews with staff, it was determined that the facility did not maintain complete and accurate medical records for four of four records reviewed related to catheter care and urinary continence. (Residents R1, R2, R4, and R5).

Inspectors wroteBased on clinical record reviews, interviews with staff and review of policies and procedures and review of emergency medications and review of Pennsylvania Professional Nurse Practice Act., it was determined that the facility failed to meet professional standards of practice related to providing routine and emergency pain medication to meet the needs of one of seven residents reviewed. (Resident R1)

Inspectors wroteBased on review of clinical record, review of facility policies, review of documentation, and interview with staff, it was determined that the facility failed to timely assess a resident for respiratory distress and failed to ensure that emergency transportation services were provided in a timely manner for one of 13 residents reviewed (Resident R158). This failure resulted in an Immediate Jeopardy situation for Resident R158 who experienced a change in condition related to respiratory distress and did not receive a timely nursing assessment and was not transferred in a timely manner to emergency room and subsequently died. (Resident R158)

Inspectors wroteBased on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure that pain management was provided consistent with physician orders for one of one resident reviewed for pain management. (Resident R98)

Inspectors wroteBased on review of clinical records, review of facility's policy and staff interview, it was determined that the facility did not ensure that a drug regimen review was conducted at least monthly and did not ensure the attending physician's reviewed/responded to pharmacist's recommendations for one of five residents reviewed. (Resident R13)

Inspectors wroteReview of facility documentation, state legislation, and interview with staff, it was determined that the facility failed to conduct a review of reportable infection to PA-PASR and report as indicated for two of six months reviewed. (May 2024 and June 2024) Findings Include: Review of act 52 of 2007 Medical Care Availability and Reduction of Error (MCARE) act chapter 4. Health care-associated infections 40 p.s. § 1303.401 - 1303.411 (2007) revealed that § 1303.404. Health care facility reporting (a) NURSING HOME REPORTING. [...]

Inspectors wroteBased on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for five of five months of antibiotic stewardship program data reviewed. (February 2024, March 2024, April 2024, May 2024 and June 2024). Findings Include: Review of facility policy Antibiotic Stewardship dated December 2016 , revealed that Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Further review of facility policy and protocol revealed that the facility policy did not include a system that includes antibiotic use protocols. [...]

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to offer and/or provide the pneumococcal immunization to five of five residents reviewed (Resident R11, R3, R96, R23 and R20).

Inspectors wroteBased on clinical record review, review of policy and procedures and staff interviews, it was determined that the facility failed to ensure that residents were offered an opportunity to develop an advance directive for one of 13 residents reviewed. (Residents R94).

Inspectors wroteBased on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented, and that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for 7 of 13 residents reviewed (Residents R148, R147, R153, R97 and R94).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to developed a personal center care plan related to elopment for one of 13 residents reviewed. (Resident R97)

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage, failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for one of two residents (Residents R97).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory study results were promptly obtained as ordered by the physician for one of 13 clinical records reviewed (Resident R94).

Inspectors wroteBased on review of facility policy, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that garbage was dispose of properly.

Inspectors wroteBased on a review of clinical records, it was determined that the faciltiy failed to ensure that elopment assessments was accurately completed for one of 13 residents reviewed (Resident R97)

Inspectors wroteBased on observations, review of facility policy and interview with staff, it was determined that facility did not ensure to maintain infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for three of 13 residents reviewed. (Resident R148, R147 and Resident R96)

Inspectors wroteBased on observations, review of clinical records, review of facility provided documentation and interview with staff and residents, it was determined that facility did not ensure to include as part of its Quality Assurance and Performance Improvement (QAPI) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for five of five employees reviewed (Employees E6, E7, E8, E9, and E10)

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan that included instructions related to a diagnosis of heart failure for one of two residents reviewed. (Resident R1).

Inspectors wroteBased on review of resident records and interviews with staff, it was determined the facility did not follow/obtain nor clarify physician orders for medication and treatments for one of two residents reviewed (Resident R1).

Inspectors wroteBased on observations, review of facility policy, and review of facility documentation it was determined that the facility did not ensure an effective infection prevention program was maintained related to hand hygiene observed for one of six residents observed. (Resident R6) Findings Include: Review of the facility policy titled, Handwashing/Hand Hygiene dated July 2023, reads, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. [...]