ElderGrade

Inspection citations at Holland Center For Rehabilitation And Nursing

45 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 1 1
2025 11 0
2024 21 1
2023 12 0
G January 29, 2026 Tag F0689 Complaint investigation Corrected Feb 2026

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D December 11, 2025 Tag F0689 Complaint investigation Corrected Dec 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

B May 16, 2025 Tag F0577 Corrected Jul 2025

Resident Rights Deficiencies

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

No actual harm, minimal potential

D May 16, 2025 Tag F0759 Corrected Jul 2025

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D May 16, 2025 Tag F0755 Corrected Jul 2025

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D May 16, 2025 Tag F0742 Corrected Jul 2025

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D May 16, 2025 Tag F0730 Corrected Jul 2025

Nursing and Physician Services Deficiencies

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

No actual harm, potential for more than minimal harm

D May 16, 2025 Tag F0695 Corrected Jul 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D May 16, 2025 Tag F0656 Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D May 16, 2025 Tag F0655 Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D May 16, 2025 Tag F0609 Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D May 16, 2025 Tag F0607 Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

E September 25, 2024 Tag F0842 Complaint investigation Corrected Oct 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D August 13, 2024 Tag F0658 Complaint investigation Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0944 Corrected Aug 2024

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0880 Corrected Aug 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0842 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0814 Corrected Aug 2024

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0812 Corrected Aug 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0770 Corrected Aug 2024

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0700 Corrected Aug 2024

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0656 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0655 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0578 Corrected Aug 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

E July 12, 2024 Tag F0883 Corrected Aug 2024

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, potential for more than minimal harm

E July 12, 2024 Tag F0881 Corrected Aug 2024

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

E July 12, 2024 Tag F0836 Corrected Aug 2024

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

E July 12, 2024 Tag F0756 Corrected Aug 2024

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

E July 12, 2024 Tag F0697 Corrected Aug 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

J July 12, 2024 Tag F0684 Complaint investigation Corrected Aug 2024

Quality of Life and Care Deficiencies

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

Immediate jeopardy to resident health or safety

D April 22, 2024 Tag F0684 Complaint investigation Corrected May 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D April 22, 2024 Tag F0655 Complaint investigation Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D February 8, 2024 Tag F0880 Complaint investigation Corrected Mar 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D October 5, 2023 Tag F0880 Corrected Nov 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D October 5, 2023 Tag F0761 Corrected Nov 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D October 5, 2023 Tag F0757 Corrected Nov 2023

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

D October 5, 2023 Tag F0755 Corrected Nov 2023

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D October 5, 2023 Tag F0697 Corrected Nov 2023

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D October 5, 2023 Tag F0693 Corrected Nov 2023

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D October 5, 2023 Tag F0684 Corrected Nov 2023

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.