12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Holland, PA
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
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
Beds
66
Certified beds
Average residents
29
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
Staffing
RN hours / resident day
1.19
Registered nurse staffing
LPN hours / resident day
0.92
Licensed practical nurse staffing
Aide hours / resident day
2.15
Nurse aide staffing
Weekend hours
3.48
Weekend nurse staffing
RN turnover
62%
Annual RN turnover
Total nurse turnover
79%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (6 deficiencies)
7 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-08
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-08-07
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-07-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-08
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-08
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-08
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-08-07
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-07-08
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-08-20
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
Fire Safety
Install proper backup exit lighting.
Corrected 2024-08-20
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-20
Fire Safety
Meet other general requirements.
Corrected 2024-08-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-20
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-12-20
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-11-24
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-24
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-11-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-24
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-01
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
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
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-01
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-07-01
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
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
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-01
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-07-01
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
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-27
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-27
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
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
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-27
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-27
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-08-27
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-08-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-27
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-08-27
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-08-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-27
Health
Dispose of garbage and refuse properly.
Corrected 2024-08-27
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-27
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-27
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-08-27
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-05-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-28
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-07
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-07
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-11-07
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-07
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-07
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-07
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-07
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-07
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-08-14
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-14
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-11
Penalties and ownership
Fine · fine $36,186
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
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