Holland Center: Safety Hazards Cause Resident Harm - PA
That was January 8, 2026, at 3:00 p.m.
The resident, identified in inspection records as Resident CL1, had a care plan that spelled out the requirement clearly: use a Hoyer lift for all transfers. The care plan also identified the resident as a fall risk with reduced balance, strength, and activity tolerance. Nursing staff had been educated on the intervention.
The nursing assistant, Employee E5, told inspectors she was unaware the resident required a mechanical lift and two or more staff members for any transfer from wheelchair to bed. She said the resident was sitting upright in her wheelchair when she entered the room and asked to be helped back to bed. Employee E5 attempted the transfer alone, without the lift.
The resident was sent emergently to the hospital. She was diagnosed with a comminuted distal fibular shaft fracture of the right leg, a transverse fracture of the medial malleolus, and dislocation of the tibiotalar joint, the joint connecting the foot to the lower leg. She required surgical repair.
The director of the therapy department confirmed to inspectors on January 29 that the care plan had been discussed with nursing staff and that the Hoyer lift was required for all transfers. She confirmed nursing staff failed to implement it.
The facility is disputing the citation.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
HOLLAND CENTER FOR REHABILITATION AND NURSING in HOLLAND, PA was cited for violations during a health inspection on January 29, 2026.
That was January 8, 2026, at 3:00 p.m.
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.