Inspection Reports for Holland Senior Living Community
1400 OLD JORDAN ROAD,, HOLLAND, PA, 18966
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
27.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
481% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
34% occupied
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 52
Capacity: 152
Deficiencies: 3
Date: Aug 18, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation following reports of incidents and concerns at the facility.
Complaint Details
The visit was complaint-related with substantiation implied by the findings of violations including failure to timely report an incident and staff qualification deficiencies.
Findings
The inspection found multiple deficiencies including failure to report an incident within 24 hours, direct care staff lacking required qualifications, and a resident support plan not signed by the resident. Plans of correction were accepted and implemented by the facility.
Deficiencies (3)
Failure to report an incident to the Department within 24 hours as required.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Resident participated in the development of support plan but did not sign the support plan.
Report Facts
License Capacity: 152
Residents Served: 52
Secured Dementia Care Unit Capacity: 27
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 9
Residents 60 Years or Older: 57
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 32
Residents with Physical Disability: 2
Total Daily Staff: 84
Waking Staff: 63
Inspection Report
Monitoring
Census: 51
Capacity: 152
Deficiencies: 10
Date: Apr 14, 2025
Visit Reason
The inspection was an unannounced partial monitoring visit conducted to review the facility's compliance with licensing requirements and the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including delayed criminal background checks for staff, insufficient CPR/First Aid certified staff during certain shifts, incomplete training records, unsecured poisonous materials, lack of emergency telephone numbers in memory care, damaged furniture and equipment, inoperable emergency exit keypad, unlocked medication carts, delayed medical evaluations for residents, and missing directions for key-locking devices. All deficiencies had plans of correction accepted and were implemented by June 26, 2025.
Deficiencies (10)
Two staff members had criminal background checks completed after their hire dates.
At times, only one staff person certified in first aid and CPR was present despite having 51 residents, not meeting the required 50:1 ratio.
Training records did not include length of training and names of all staff trained.
An aerosol can of hairspray was unlocked and accessible to residents in the secure dementia care unit activities room.
No emergency telephone numbers were posted on or by the telephone in memory care on the nurse's desk.
A smoke detector near a resident's room was dangling from the ceiling by its wires.
The gate door and keypad in the memory care courtyard were inoperable, with the keypad giving no feedback and the door remaining locked.
Medication carts were found unlocked, unattended, and accessible in the memory care dining room and nurses area.
A resident admitted to the memory care unit had a medical evaluation completed after admission, not within 60 days prior as required.
Directions for operating the home's locking mechanism were not conspicuously posted near the exit door by a resident's room in the secured dementia care unit.
Report Facts
Residents served: 51
License capacity: 152
Staff hours: 80
Waking staff hours: 60
Residents in secured dementia care unit: 9
Capacity of secured dementia care unit: 25
Current hospice residents: 6
Residents with mobility need: 29
Residents aged 60 or older: 51
Residents receiving Supplemental Security Income: 9
Residents with physical disability: 1
Inspection Report
Monitoring
Census: 63
Capacity: 152
Deficiencies: 2
Date: Feb 25, 2025
Visit Reason
The inspection was an unannounced partial monitoring visit conducted to review the facility's compliance with regulations and the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction. Two specific deficiencies were noted: an unlocked cabinet containing poisonous materials accessible to residents, and medication cards with punctured blister foil exposing medication to contamination. Corrective actions and ongoing monitoring plans were in place and implemented.
Deficiencies (2)
An unlocked cabinet under the bathroom sink in a secured unit contained a tube of Procare vitamin A & D ointment accessible to residents not assessed as capable of safely using poisonous materials.
Medication cards were observed to have punctured blister foil with medication still present, exposing it to contamination and improper sanitation.
Report Facts
License Capacity: 152
Residents Served: 63
Residents in Secured Dementia Care Unit: 12
Current Hospice Residents: 5
Residents with Mobility Need: 42
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 2
Total Daily Staff: 105
Waking Staff: 79
Inspection Report
Complaint Investigation
Census: 57
Capacity: 152
Deficiencies: 7
Date: Jan 28, 2025
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation related to a resident elopement and other compliance concerns at the facility.
Complaint Details
The visit was complaint-related, triggered by an incident involving resident elopement and concerns about resident safety and care.
Findings
The facility was found to have multiple violations including resident elopement due to inadequate supervision, direct care staff lacking required qualifications, insufficient staffing to meet resident needs, inadequate CPR/First Aid coverage, incomplete medical evaluations for secured dementia care unit residents, missing preadmission cognitive screenings, and lack of documentation of no objection statements for secured unit admissions.
Deficiencies (7)
Resident eloped from the secured dementia care unit due to inadequate supervision and staffing.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Staffing was insufficient to meet the supervision needs of residents, with only one direct care staff responsible for 10 residents on the secured dementia care unit.
Only one staff person certified in first aid and CPR was present during the night shift despite residents being present.
Resident medical evaluation did not document diagnosis of dementia or need for secured dementia care unit placement.
Written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
No documentation that the resident and designated person had not objected to admission or transfer to the secured dementia care unit.
Report Facts
License Capacity: 152
Residents Served: 57
Residents in Secured Dementia Care Unit: 9
Current Residents in Hospice: 6
Total Daily Staff: 99
Waking Staff: 74
Residents per Direct Care Staff on SDCU during incident: 10
Outdoor Temperature at Elopement: 33
Inspection Report
Complaint Investigation
Census: 60
Capacity: 152
Deficiencies: 6
Date: Dec 19, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Holland Senior Living Community on 12/19/2023.
Complaint Details
The visit was complaint-related, triggered by incidents of resident elopement and contract/signature issues. The complaint was substantiated with findings of inadequate supervision and alarm system failures.
Findings
The inspection found multiple deficiencies including failure to obtain resident signatures on contracts, inadequate supervision leading to resident elopements from the Memory Care Unit, insufficient volume of exit door alarms, and incomplete or unsigned support plans. Plans of correction were submitted and fully implemented by 03/12/2024.
Deficiencies (6)
Resident did not sign her initial contract upon moving into the personal care home.
Resident eloped from the Memory Care Unit due to inadequate supervision and alarm system limitations.
Exit door alarm volume was insufficient and not audible throughout the memory care unit.
Support plans were not revised after resident elopements and changes in needs.
Assessor did not sign the resident's support plan.
No documentation that the resident and designated person did not object to admission to the secured dementia care unit.
Report Facts
License Capacity: 152
Residents Served: 60
Memory Care Unit Capacity: 27
Memory Care Residents Served: 15
Current Hospice Residents: 5
Resident Mobility Need: 30
Residents with Physical Disability: 3
Residents Age 60 or Older: 59
Inspection Report
Renewal
Census: 63
Capacity: 152
Deficiencies: 18
Date: Aug 22, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the Holland Senior Living Community to assess compliance with state regulations and verify correction of previous deficiencies.
Findings
The inspection identified multiple deficiencies including delayed refunds after resident deaths, lack of privacy signage, sanitary issues in the kitchen, improper trash storage, inadequate bedside lighting, food storage violations, fire safety equipment issues, delayed fire safety inspections, evacuation drill timing failures, incomplete medical evaluations, medication administration errors, incomplete preadmission screenings, incomplete support plans, and incomplete resident record content. Plans of correction were accepted and implemented by October 2023.
Deficiencies (18)
Refunds were not sent out within a 30 day period of discharge following resident deaths.
No signs posted outside the main entrance indicating video recording.
Mold-like substance found inside ice machine and stains on kitchen carpets.
Bulk trash items placed outside dumpsters.
Resident did not have access to operable bedside lamp.
Food and water stored directly on the floor.
Leftover food items in freezer were unlabeled and undated.
No fire extinguishers available in one facility vehicle.
Fire extinguishers in vehicles not inspected since 2018 or missing tags.
Fire safety inspection and drill not completed annually; last inspection in September 2021.
Evacuation drills exceeded the maximum safe evacuation time specified by fire safety expert.
Medical evaluations for residents 7 and 8 did not include medical information pertinent to emergency treatment.
Resident 9 was administered incorrect medication dosage due to unavailability of prescribed dose.
Preadmission screening forms for residents 7 and 10 lacked determination that needs could be met by the home.
Support plan for resident 8 did not document how thin liquid needs would be met.
Residents 11 and 12 participated in support plan development but did not sign the plans.
Support plans for residents 8 and 11 were not completed within 72 hours of admission to secured dementia care unit.
Resident records for multiple residents lacked race, hair color, or eye color information.
Report Facts
License Capacity: 152
Residents Served: 63
Memory Care Unit Capacity: 27
Memory Care Residents Served: 12
Hospice Residents: 7
Residents with Mental Illness: 11
Residents with Mobility Need: 30
Residents with Physical Disability: 2
Total Daily Staff: 93
Waking Staff: 70
Boxes of Water Stored on Floor: 42
Inspection Report
Renewal
Census: 57
Capacity: 152
Deficiencies: 22
Date: Aug 15, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Holland Senior Living Community.
Findings
The inspection identified multiple deficiencies including incomplete criminal background checks, insufficient CPR certified staff on certain shifts, lack of fire safety orientation for some staff, improper medication storage and documentation, incomplete medical evaluations and screenings for residents, and missing manufacturer statements for secure dementia care unit locks. Plans of correction were submitted and accepted with implementation dates noted.
Deficiencies (22)
Staff person A did not have a criminal history background check completed prior to hire.
Only one staff person certified in first aid, obstructed airway techniques and CPR was present during shifts with 52 and 53 residents.
Staff person B did not receive orientation on evacuation procedures, fire drills, emergency evacuation, smoking safety, fire extinguishers, smoke detectors, fire alarms, telephone use and emergency notification.
Staff person B did not complete 40-hour orientation training on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents.
Ancillary staff person A did not have a general orientation to specific job functions prior to working in that capacity.
The home did not have a staff training plan for the 2022 training year.
Uncovered, unattended trash can found in the Lower West trash room.
Resident #1 did not have access to a source of light that can be turned on/off at bedside.
Approximate 1/4 inch accumulation of lint in the lint trap of the dryer in the Upper East wing.
Written emergency procedures have not been submitted to the local emergency management agency since June 2021.
Fire drill records did not include number of residents in the home or number evacuated during drills from 12/3/21 to 7/27/22.
Fire drills were conducted on the same day of the week (Wednesdays) rather than different days and times.
No record that residents evacuated to a designated meeting place during fire drills from 12/3/21 to 7/27/22.
Loose pills found in Lower West medication cart.
Medications prescribed to Resident #2 were not present on the medication cart or available for use; glucose readings did not match recorded logs for multiple dates.
Resident #3 and #4 had discrepancies between glucose meter readings and recorded logs.
Resident #2 was administered insulin doses inconsistent with glucometer readings; multiple glucose log entries had no corresponding glucometer readings.
Resident #5 admitted to Secure Dementia Care Unit without a current medical evaluation within 60 days prior to admission.
Resident #5 admitted to Secure Dementia Care Unit without a written cognitive preadmission screening completed within 72 hours prior to admission.
No manufacturer statement verifying magnetic locking system will release upon fire alarm activation, power failure, or lock release device operation for secure dementia care unit.
Directions for operating locking mechanisms at exterior doors to Secure Dementia Care Unit were not conspicuously posted.
Resident #5 and #6 admitted to Secure Dementia Care Unit without initial support plans developed within 72 hours of admission.
Report Facts
Residents served: 57
License capacity: 152
Staff certified in CPR: 1
Trash can fullness: 0.25
Lint accumulation: 0.25
Fire drills on same weekday: 6
Loose pills found: 2
Glucose check frequency: 3
Plan completion date: Sep 22, 2022
Plan completion date: Sep 30, 2022
Plan completion date: Sep 15, 2022
Plan completion date: Sep 9, 2022
Plan completion date: Sep 8, 2022
Inspection Report
Complaint Investigation
Census: 50
Capacity: 152
Deficiencies: 1
Date: Aug 1, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with licensing requirements at the facility.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The plan of correction was fully implemented and compliance was maintained.
Findings
The inspection found a violation related to the lack of toilet paper in two out of three bathroom stalls, which was corrected with a plan of correction implemented and verified.
Deficiencies (1)
No toilet paper immediately available for resident while in restroom in two out of three bathroom stalls.
Report Facts
License Capacity: 152
Residents Served: 50
Residents Served in Memory Care: 7
Resident Support Staff Hours: 50
Total Daily Staff: 125
Waking Staff: 94
Residents Diagnosed with Mental Illness: 1
Residents Are 60 Years of Age or Older: 50
Residents Have Mobility Need: 25
Inspection Report
Complaint Investigation
Census: 57
Capacity: 152
Deficiencies: 3
Date: May 25, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The inspection was triggered by a complaint. The complaint was substantiated as deficiencies were found related to resident care and facility operations.
Findings
The inspection found deficiencies related to delayed response to a resident's call bell, inadequate staffing leading to closure of the dining room for meals on multiple days, failure to post weekly menus in certain care units, and issues with meal service in the dining room. Plans of correction were accepted and implemented to address these issues.
Deficiencies (3)
Resident pressed call bell for assistance and call bell was not answered in a timely manner, with a delay of nearly an hour.
Meal service was not provided in the dining room on multiple days due to lack of staff, resulting in dining room closures for breakfast and/or dinner.
The home's menu for the week of 5/23/22 was not posted in Personal Care or Memory Care units.
Report Facts
License Capacity: 152
Residents Served: 57
Call bell response delay: 55.56
Dietary staff count on 5/21/22: 3
Dietary staff count on 5/22/22: 2
Inspection Report
Plan of Correction
Census: 57
Capacity: 152
Deficiencies: 2
Date: Feb 9, 2022
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a submitted plan of correction related to prior deficiencies at Holland Senior Living Community.
Findings
The submitted plan of correction was determined to be fully implemented, addressing issues of resident abuse and privacy violations involving a staff member who stole a resident's debit card. The staff member was terminated and staff received education on abuse and privacy rights.
Deficiencies (2)
Staff person A stole resident 1’s debit card from the resident’s purse and used it to withdraw cash from the resident’s bank account.
Violation of resident privacy rights related to theft of debit card from resident’s purse.
Report Facts
License Capacity: 152
Residents Served: 57
Secured Dementia Care Unit Capacity: 27
Secured Dementia Care Unit Residents Served: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings related to theft and abuse of resident |
Inspection Report
Follow-Up
Census: 52
Capacity: 152
Deficiencies: 6
Date: Jan 6, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to resident care, staff training, medical evaluations, and assessments. The submitted plan of correction was determined to be fully implemented, with continued compliance required.
Deficiencies (6)
Resident #1 did not receive assistance with ambulating as required; call bell response was delayed resulting in resident found on the floor.
Staff person A did not complete required training within 40 scheduled working hours including emergency medical plan and mandatory reporting of abuse and neglect.
The home's annual training plan for 2021 did not include training in falls and accident prevention.
Resident #1's medical evaluation did not include required medical diagnoses and other elements.
Resident #1's initial assessment was not completed within 15 days of admission.
Resident #1 was not re-assessed after multiple falls in 2021 and 2022.
Report Facts
Total Daily Staff: 69
Waking Staff: 52
License Capacity: 152
Residents Served: 52
Secured Dementia Care Unit Capacity: 27
Secured Dementia Care Unit Residents Served: 7
Current Hospice Residents: 5
Residents Age 60 or Older: 51
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 61
Capacity: 152
Deficiencies: 4
Date: Nov 19, 2021
Visit Reason
The inspection was a monitoring visit conducted on 11/19/2021 to review the facility's compliance and verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have several deficiencies including missing posted directions for key-locking devices, unlocked poisonous materials accessible to residents, lack of thermometer in a refrigerator, and menus not posted as required. The submitted plan of correction was determined to be fully implemented.
Deficiencies (4)
Directions for operating the home's locking mechanism were not conspicuously posted near three doors in the Secure Dementia Care Unit.
Poisonous materials such as antiperspirant, fluoride toothpaste, and cleanser were unlocked, unattended, and accessible to residents in the memory care unit.
No thermometer was present in the GE refrigerator in the memory care unit's kitchenette.
The home's menu for the current and following week was not posted in a conspicuous and public place in the home.
Report Facts
License Capacity: 152
Residents Served: 61
Memory Care Unit Capacity: 27
Memory Care Unit Residents Served: 13
Total Daily Staff: 85
Waking Staff: 64
Inspection Report
Follow-Up
Census: 67
Capacity: 152
Deficiencies: 14
Date: Nov 1, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 11/01/2021 and 11/02/2021 to review the submitted plan of correction related to a prior incident.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including resident abuse reporting, supervision, notification, incident reporting, resident contracts, medication management, and resident rights. Continued compliance and ongoing staff education were emphasized.
Deficiencies (14)
Failure to immediately report suspected abuse of a resident in accordance with Older Adult Protective Services Act.
Failure to immediately suspend staff person involved in alleged abuse or develop a supervision plan.
Failure to notify resident's designated person of suspected abuse.
Failure to report incident to the department within required timeframe.
Resident #1 did not have a resident-home contract completed upon admission.
Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Resident abuse: resident was grabbed by staff causing bruises; staff did not take complaint seriously; verbal mistreatment and neglect reported.
Failure to treat resident with dignity and respect; staff entered room without knocking and argued with resident; medication administration refusal.
Resident medical evaluation incomplete; missing general physical exam, immunization history, and medication self-administration ability.
Expired and discontinued medications found on medication cart.
Failure to follow prescriber's orders including vital signs, medication application, and COVID surveillance.
Resident not educated on right to refuse medication if medication error suspected.
Failure to implement positive interventions to modify or eliminate resident behaviors of irritability and agitation.
No preadmission screening completed for resident #1.
Report Facts
License Capacity: 152
Residents Served: 67
Memory Care Capacity: 27
Memory Care Residents Served: 12
Hospice Residents: 6
Staffing Hours: 98
Waking Staff: 74
Inspection Report
Original Licensing
Census: 60
Capacity: 152
Deficiencies: 11
Date: May 11, 2021
Visit Reason
The inspection was conducted due to a change in legal entity and as part of the initial licensing process for the newly licensed facility.
Findings
The facility was found to be in substantial compliance with applicable regulations, but several deficiencies were cited including unlocked poisonous materials accessible to residents, trash improperly stored outside, hot water temperature exceeding limits, staff unaware of first aid kit location, water leaks, improper freezer temperature, lint accumulation in dryer, missing emergency management agency submission, inoperable smoke detector procedures, overdue fire extinguisher inspections, and outdated posted menus.
Deficiencies (11)
Unlocked poisonous materials accessible to resident 1 in the memory care unit.
Trash (wood pallets, debris) improperly stored outside the home.
Hot water temperature in bathroom in room 2109 measured 122.9°F, exceeding the 120°F limit.
Staff person did not know the location of the first aid kit.
Water leaking from ceiling inside boiler room and entrance of laundry room; stained ceiling tiles from water damage.
Freezer temperature was 18°F, exceeding the required maximum of 0°F.
Approximately 2 inches of lint accumulation in lint trap of dryer in main laundry room.
Facility unable to provide annual written emergency procedures signed by local emergency management agency.
Emergency procedures do not indicate actions when smoke detector or fire alarms are inoperable.
Fire extinguishers in multiple locations had not been inspected by a fire safety expert for over a year.
Weekly menu for May 9-15 was not posted; posted menu outside dining room was outdated.
Report Facts
License Capacity: 152
Residents Served: 60
Secure Dementia Care Unit Capacity: 27
Secure Dementia Care Unit Residents Served: 12
Staffing: 92
Waking Staff: 69
Hot Water Temperature: 122.9
Freezer Temperature: 18
Lint Accumulation: 2
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