Holland, PA

Holland Center For Rehabilitation And Nursing

3-star overall rating with 2-star inspections with $36,186 in total fines with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

280 Middle Holland Road, Holland, PA

(215) 322-6100

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Lme Family Holdings

Operator or chain grouping

Approved since

1979-06-01

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

15 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.19

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.92

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.15

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.26

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

2.11

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.48

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.73

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.31

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.06

CMS adjusted RN staffing hours

Adjusted total hours

3.79

CMS adjusted total nurse staffing hours

Case-mix index

1.54

Higher values indicate more complex resident acuity

RN turnover

62%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

79%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,747

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.71

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 23.94% · Performance 24.18% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.47

Baseline 7.68% · Performance 7.40% · Measure score 1.47 · Achievement 1.47 · Improvement 0.56

Total nurse turnover

Baseline 50.94% · Performance 87.65% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.82

Baseline 3.43 hours · Performance 3.88 hours · Measure score 2.82 · Achievement 2.82 · Improvement 1.41

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.65%	10.72% 0.9 pts worse	No Different than the National Rate · Eligible stays 384 · Observed rate 12.24% · Lower 95% interval 9.41%
Discharge to community	52.3%	50.57% 1.7 pts better	No Different than the National Rate · Eligible stays 402 · Observed rate 46.27% · Lower 95% interval 46.25%
Medicare spending per beneficiary	1.12	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 183 · Denominator 183
Falls with major injury	1.64%	0.77% 0.9 pts worse	Numerator 3 · Denominator 183
Discharge self-care score	46.34%	53.69% 7.3 pts worse	Numerator 57 · Denominator 123
Discharge mobility score	43.9%	50.94% 7 pts worse	Numerator 54 · Denominator 123
Pressure ulcers or injuries, new or worsened	2.73%	2.29% 0.4 pts worse	Numerator 5 · Denominator 183 · Adjusted rate 2.51%
Healthcare-associated infections requiring hospitalization	7.4%	7.12% 0.3 pts worse	No Different than the National Rate · Eligible stays 234 · Observed rate 7.69% · Lower 95% interval 5.37%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 102
Staff flu vaccination coverage	21.95%	42% 20.1 pts worse	Numerator 18 · Denominator 82
Discharge function score	41.46%	56.45% 15 pts worse	Numerator 51 · Denominator 123
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 69 · Denominator 69
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 99 · Denominator 99
Resident COVID-19 vaccinations up to date	35.29%	25.2% 10.1 pts better	Numerator 30 · Denominator 85

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.2%	86.9% 11.3 pts better	93.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 98.2%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.2% 3.2 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	8.0%	6.5% 1.5 pts worse	11.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.0%
Percentage of long-stay residents who lose too much weight	15.6%	6.5% 9.1 pts worse	5.4% 10.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.6%	19.9% 4.3 pts better	19.6% 4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6%
Percentage of long-stay residents who received an antipsychotic medication	4.2%	18.7% 14.5 pts better	16.7% 12.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased	0.0%	18.3% 18.3 pts better	14.9% 14.9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
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 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.3%	26.4% 4.1 pts better	19.8% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 22.3%
Percentage of long-stay residents with pressure ulcers	6.2%	5.3% 0.9 pts worse	5.1% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	88.3%	68.9% 19.4 pts better	81.7% 6.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 68.6% · Q2 95.3% · Q3 98.0% · Q4 97.7% · 4Q avg 88.3%
Percentage of short-stay residents who had an outpatient emergency department visit	3.2%	9.8% 6.6 pts better	12.0% 8.8 pts better	Short Stay · 20240701-20250630 · Adjusted 3.2% · Observed 3.1% · Expected 10.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.6%	68.7% 25.9 pts better	79.7% 14.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.3%	23.1% 4.2 pts worse	23.9% 3.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 26.6% · Expected 23.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-16 · Fire 2025-05-16

12 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-07-12 · Fire 2024-07-12

20 health deficiencies

Top issue: Resident Assessment and Care Planning (6 deficiencies)

7 fire-safety deficiencies

Top issue: Construction (2 deficiencies)

Cycle 3 Health 2023-10-05 · Fire 2023-10-05

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-08-07

F · Potential for more than minimal harm 2025-05-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2025-08-07

E · Potential for more than minimal harm 2025-05-16

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2025-08-07

C · Minimal harm 2025-05-16

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-07-08

E · Potential for more than minimal harm 2024-07-12

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-08-20

E · Potential for more than minimal harm 2024-07-12

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-08-20

E · Potential for more than minimal harm 2024-07-12

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-08-20

E · Potential for more than minimal harm 2024-07-12

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-08-20

E · Potential for more than minimal harm 2024-07-12

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-08-20

C · Minimal harm 2024-07-12

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-08-20

C · Minimal harm 2024-07-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-20

E · Potential for more than minimal harm 2023-10-05

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2023-12-20

E · Potential for more than minimal harm 2023-10-05

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-10-05

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-10-05

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-10-05

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-11-24

C · Minimal harm 2023-10-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-24

Inspection history

Recent health citations

G · Actual harm 2026-01-29

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.

Not marked corrected

D · Potential for more than minimal harm 2025-12-11

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 2025-12-12

D · Potential for more than minimal harm 2025-05-16

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-05-16

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-05-16

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 2025-07-01

D · Potential for more than minimal harm 2025-05-16

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 2025-07-01

D · Potential for more than minimal harm 2025-05-16

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-05-16

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-05-16

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-05-16

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 2025-07-01

D · Potential for more than minimal harm 2025-05-16

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-07-01

B · Minimal harm 2025-05-16

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2025-07-01

E · Potential for more than minimal harm 2024-09-25

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-10-29

D · Potential for more than minimal harm 2024-08-13

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-09-03

J · Immediate jeopardy 2024-07-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-07-12

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-07-12

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-07-12

F836 · Administration Deficiencies

Health

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-07-12

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-07-12