Pennsylvania Department of Health
HOLLAND CENTER FOR REHABILITATION AND NURSING
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 47 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


HOLLAND CENTER FOR REHABILITATION AND NURSING - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 28, 2025, it was determined that Holland Center for Rehab had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility.

Findings include:
Document review on May 28, at 8:00 a.m., revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually.

Exit interview with the Administrator and Maintenance Director on May 28, at 2:30 p.m., confirmed procedural updated documentation could not be provided.

Plan of Correction - To be completed: 07/08/2025

1) The Facility's Emergency Preparedness Plan will be reviewed and updated within the next month so that it is done annually.
2) The NHA will receive education regarding the components of this regulation.
3) The NHA and/or designee will perform audits monthly for the next four months to ensure that the facility's Emergency Preparedness Plan has been reviewed and updated.
Results of the audits will be reported to QAPI meeting

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 071202
Component 01
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on May 28, 2025, it was determined that Holland Center For Rehabilitation And Nursing was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to ensure common wall fire separations maintained a fire resistance rating affecting one of three levels.

Findings include:

Observation made on May 28, 2025, from 11:40 a.m. to 11:50 a.m. revealed fire rated door deficiencies at the following locations:

a. 11:40 a.m., double fire door with several penetrations on door leaf and several penetrations in the metal door frame, in the basement, Elevator Lobby leading to laundry corridor.
b. 11:50 a.m., fire door with penetrations and extensive damage at each hinge location, in the basement, Elevator Lobby, Dry Storage.

Exit interview with the Administrator and Maintenance Director on May 28, 2025, at 2:30 p.m., confirmed the fire door deficiencies.

Plan of Correction - To be completed: 07/08/2025

1) The penetrations in the double fire door and the metal door frame in the basement, elevator lobby will be repaired by installing a metal fastener that completely seals the hole.
The fire door with penetrations and extensive damage at each hinge location in the basement will be replaced.
2) Other fire doors in the center will be checked to ensure they are free of penetrations and the hinges are not damaged.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure that the fire doors are free from penetrations and the hinges are not damaged.
Results of the audits will be reported to QAPI meeting.

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting two of three levels.

Findings include:

Observation on May 28, 2025, at 10:20 a.m., revealed fire barrier deficiencies at the following locations:

a. 11:45 a.m., multiple wall penetrations surrounding wires and electrical conduit, above ceiling tile, in the basement, Elevator Lobby near Dry Storage Door.
b. 12:05 p.m., wall penetration surrounding a blue data line, above ceiling tile at the double doors, in the basement, near Salon.
c. 12:35 p.m. wall penetration surrounding electrical lines, above ceiling tile at the double doors, on the first floor, Elevator Lobby.
d. 1:12 p.m., wall penetration surrounding electrical lines, above ceiling tile far right side of elevator shaft, on the second floor, Elevator Lobby.

Exit interview with the Administrator and Maintenance Director on May 28, 2025, at 2:30 p.m., confirmed the fire barrier deficiencies.

Plan of Correction - To be completed: 07/08/2025

K 133
1) The multiple wall penetrations surrounding wires and electrical conduit above the ceiling tile in the basement elevator lobby near the dry storage door will be repaired using an approved fire rated material.
The wall penetration surrounding the blue data line above the ceiling tile at the double doors in the basement near the Salon will be repaired using an approved fire rated material.
The wall penetration surrounding the electrical lines above the ceiling tile at the double doors on the first floor, elevator lobby will be repaired using an approved fire rated material.
The wall penetration surrounding electrical lines above ceiling tile far right side of elevator shaft, on the second floor elevator lobby will be repaired using an approved fire rated material.
UPDATE: These penetrations will be repaired utilizing SpecSeal LCI sealant using through penetration Firestop System 3210.
2) Other fire barriers in the center will be checked to ensure they are free from penetrations.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure fire barriers are free from penetrations.
Results of the audits will be reported to QAPI meeting.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based upon observation and interview, it was determined the facility failed to ensure exit signs were maintained, affecting one of three levels.

Findings include:

Observation on May 28, 2025, at 12:35 p.m., revealed the exit sign failed to illuminate, in the basement, corridor near Sprinkler Room.

Exit interview with the Administrator and Maintenance Director on May 28, 2025, at 2:30 p.m., confirmed the deficient exit sign.

Plan of Correction - To be completed: 07/08/2025

K293
1) The exit sign in the basement corridor near the sprinkler room was fixed so that it illuminates.
2) Other exit signs in the center will be checked to ensure that they illuminate.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure exit signs are illuminated.
Results of the audits will be reported to QAPI meeting.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation review and interview, it was determined the facility failed to maintain the fire alarm system in proper operating condition, affecting the entire facility.

Findings Include:

Observation on May 28, 2025, at 1:45 p.m., revealed the facility fire alarm panel was in trouble mode at the time of survey, front lobby office area.

Exit interview with the Administrator and Maintenance Director on May 28, 2025, at 2:30 p.m., confirmed the fire alarm panel trouble mode.

Plan of Correction - To be completed: 07/08/2025

K345
1) The facility fire panel will be repaired so that it is not in trouble mode.
2) Other fire panels in the center will be checked to ensure that they are not in trouble mode.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure fire panels are not in trouble mode.
Results of the audits will be reported to QAPI meeting.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were accessible, affecting one of three levels.

Findings Include:

Observation on May 28, 2025, at 12:19 p.m., revealed an ABC portable fire extinguisher wall mounted in the basement housekeeping storage room was obstructed by several vacuums.
Exit interview with the Administrator and Maintenance Director on May 28, at 2:30 p.m., confirmed access to the portable fire extinguisher was obstructed.

Plan of Correction - To be completed: 07/08/2025

K355
1) The several vacuums were moved that were obstructing the ABC portable fire extinguisher.
2) Other fire extinguishers have been checked to ensure that they are accessible.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure that fire extinguishers are accessible.
Results of the audits will be reported to QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374
Based on observation and interview, it was determined the facility failed to ensure smoke barrier doors were smoke tight, affecting one of three levels.

Findings include:

Observation on May 28, 2025, at 12:27 p.m. revealed cross corridor doors on the first floor near the salon within a smoke compartment had a gap greater than 1 1/2 inches that would not resist the passage of smoke.

Exit interview with the Administrator and Maintenance Director on May 28, 2025, at 2:30 p.m., confirmed the door deficiencies.

Plan of Correction - To be completed: 07/08/2025

K374
1) The cross corridor doors on the first floor near the salon within a smoke compartment will be fixed to ensure that it is smoke tight.
2) Other smoke barrier doors in the center will be checked to ensure they are smoke tight.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure that smoke barrier doors are smoke tight.
Results of the audits will be reported to QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined that the facility failed to maintain protection of electrical wiring, affecting one of three levels.

Findings include:

1. Observation on May 28, 2025, at 12:14 p.m., revealed an open junction box with exposed wiring located in the basement phone room.

2. Observation made on May 28, 2025, at 12:50 p.m.., revealed electrical deficiencies at the Storage Room across from the Health Care Administrators Office:

a. Two electrical panels labeled DP 2 and DP 4 being blocked by storage within three feet.
b. One electrical panel labeled DP 4 had a broken latch and could not be easily opened.

Exit interview with the Administrator and Maintenance Director on May 28, 2025, at 2:30 p.m., confirmed the electrical deficiencies.

Plan of Correction - To be completed: 07/08/2025

K911
1) The open junction box will be checked to eliminate any exposed wiring in the basement phone room.
Storage will be moved three feet from the two electrical panels labled DP2 and DP4.
Electrical panel labeled DP4 had its latch repaired so that it can be easily opened.
2) Other electrical panels will be checked to ensure that there are no storage within 3 feet of the panel.
Other electrical panels will be checked to ensure that they open easily.
Other junction boxes in the center will be checked to ensure there are no open wiring.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure that smoke barrier doors are smoke tight.
Results of the audits will be reported to QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

Observation on May 28, 2025, at 12:55 p.m., revealed the emergency generator annunciator panel was in trouble mode, on the first floor Nurses Station.

Exit interview with the Administrator and Maintenance Director on May 28, 2025, at 2:30 p.m., confirmed the annunciator panel trouble mode.

Plan of Correction - To be completed: 07/08/2025

K918
1) The company that maintains our generator came in to resolve the issue that cause the annunciator panel to be in trouble mode.
2) The generator comes out on a routine basis to inspect and resolve any issues regarding the generator. In between visits it is monitored by our Maintenance staff.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure that the annunciator panel for he generator is not in trouble mode.
Results of the audits will be reported to QAPI meeting.

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