Holland Center: Safety Hazards Cause Resident Harm - PA
Resident CL1's care plan specifically required use of a Hoyer lift for all transfers, with nursing staff educated on this intervention to prevent falls. The resident was identified as having reduced balance, strength and activity tolerance.
On January 8, 2026, at 3:00 p.m., Resident CL1 rang the call bell from their wheelchair in the bedroom. Nursing Assistant Employee E5 responded and found the resident starting to slide, requesting help getting back to bed.
Instead of using the required mechanical lift, Employee E5 placed a walker in front of the resident. Upon standing, Resident CL1 fell to the floor. Blood was visible near the resident after the fall.
The resident was rushed to the emergency room and diagnosed with a comminuted distal fibular shaft fracture of the right leg, transverse fracture of the medial malleolus, and dislocation of the tibiotalar joint connecting the foot to the lower leg. All injuries required surgical repair.
Employee E5 told inspectors three weeks later that she was "unaware" Resident CL1 required a mechanical lift and assistance from two or more staff members for safe transfers. She confirmed she attempted the transfer alone.
The therapy director confirmed the care plan had been discussed with nursing staff and that Employee E5 "failed to implement the interventions and assistive device as indicated on the care plan."
The facility is disputing the citation for actual harm to the resident.
Resident CL1 was admitted to the hospital for treatment of the open ankle fracture caused by the nursing assistant's failure to follow established safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Holland Center For Rehabilitation and Nursing from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HOLLAND CENTER FOR REHABILITATION AND NURSING in HOLLAND, PA was cited for violations during a health inspection on January 29, 2026.
Resident CL1's care plan specifically required use of a Hoyer lift for all transfers, with nursing staff educated on this intervention to prevent falls.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.