Holland Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Holland Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 12, 2024

  Based on review of clinical record, review of facility policies, review of documentation, and interview with staff, it was determined that the facility failed to timely assess a resident for respiratory distress and failed to ensure that emergency transportation services were provided in a timely manner for one of 13 residents reviewed (Resident R158). This failure resulted in an Immediate Jeopardy situation for Resident R158 who experienced a change in condition related to respiratory distress and did not receive a timely nursing assessment and was not transferred in a timely manner to emergency room and subsequently died . […]

• Actual harm, isolatedF689Jan 29, 2026

  Based on review of information submitted by the facility, hospital records, clinical records, policy and procedures, and interviews with residents and staff, it was determined the facility failed to ensure resident received adequate assistance and supervision with assistive devices to prevent accidents for one of eight residents reviewed for falls and functional abilities. Resident CL1 fell during an attempted improper transfer with staff causing the resident actual harm. (Resident CL1).Findings include:Review of the facility's undated policy and procedure titled Comprehensive person-centered care plans revealed it was the responsibility of the interdisciplinary care team to develop and implement a care plan for each resident with measurable objectives and time frames to meet the… […]

• No harm, potential for more than minimal, patternF842Sep 25, 2024

  Based on observation, clinical record review, and interviews with staff, it was determined that the facility did not maintain complete and accurate medical records for four of four records reviewed related to catheter care and urinary continence. (Residents R1, R2, R4, and R5). Findings include: Review of clinical documentation revealed that Resident R1 was admitted to the facility on [DATE], and had diagnoses of fracture of right tibia, fracture of left tibia, fracture of left fibula, and morbid obesity. Review of the resident's clinical record revealed that she utilized an indwelling urinary catheter (a tube inserted into the bladder through the urethra in order to assist in emptying it of urine, and which stays in place for an extended period of time). […]

• No harm, potential for more than minimal, patternF697Jul 12, 2024

  Based on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure that pain management was provided consistent with physician orders for one of one resident reviewed for pain management. (Resident R98) Findings include: Interview with Resident R98 on July 10, 2024, at 9:53 a.m. revealed that she was not receiving pain medication as ordered. She stated when she was not receiving pain medication when her pain level was 10 of a scale of 10. It also affected her activities and sleep. She stated did not receive her morphine sulfate pain medication for over 48 hours. Resident stated she has pain to lower back, right leg, and left leg pain radiates down to the foot. […]

• No harm, potential for more than minimal, patternF756Jul 12, 2024

  Based on review of clinical records, review of facility's policy and staff interview, it was determined that the facility did not ensure that a drug regimen review was conducted at least monthly and did not ensure the attending physician's reviewed/responded to pharmacist's recommendations for one of five residents reviewed. (Resident R13) Findings include: Review of facility's policy medication regimen reviews, revealed that the consultant pharmacist performs a medication regimen review (MMR) for every resident in the facility receiving medication, and MRR's are done upon admission and at least monthly thereafter, or more frequently if indicated. […]