Holland Senior Living Community.

“The telephone number of the complaint hotline for the personal care home was not posted in a conspicuous and public place in the home.”

“The administrator completed only 15 hours of Department-approved training in the training year 2025, falling short of the required 24 hours of annual training relating to job duties.”

“Staff person B did not receive training in medication self-administration and safe management techniques during training year 2025. Staff person C did not receive training in safe management techniques during training year 2025.”

“Staff person C did not receive training in fire safety and falls and accident prevention during training year 2025. Staff person D did not receive training in falls and accident prevention during training year 2025. Staff person E did not receive training in fire safety, emergency preparedness procedures, resident rights, Older Adult Protective Services Act, and falls and accident prevention during training year 2025.”

“In room 2209, poisonous materials including Colgate toothpaste, bar of soap, Listerine mouthwash, and Nature's Promise laundry detergent with a poison control warning label were unlocked, unattended, and accessible to residents. Not all residents were assessed as capable of recognizing and using poisons safely.”

“A resident reported to staff that a male came into their room and touched them with their penis. The home did not submit an incident report to the Department within 24 hours as required.”

“Direct care staff person B does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, which are required qualifications for direct care staff.”

“A resident participated in the development of their support plan but did not sign and date the support plan as required.”

“Training records for direct care staff did not include the length of training and names of all staff persons trained for sessions occurring on specified dates. Another training record lacked the length and source of training information.”

“Two staff members had criminal background checks completed after their hire dates, violating the requirement that background checks be completed prior to or at the time of hiring.”

“During three separate occasions from 3:00 PM to 7:00 AM, only one staff person certified in first aid, obstructed airway techniques, and CPR was present in the home with 51 residents, failing to meet the required 1 certified staff per 50 residents ratio.”

“An aerosol can of Aquanet hair spray labeled "keep out of reach of children, inhaling can be harmful or fatal" was unlocked, unattended, and accessible to residents in a lower cabinet in the secure dementia care unit activities room. Not all residents were assessed as capable of safely recognizing and avoiding poisonous materials.”

“Emergency telephone numbers for the nearest hospital and fire department were not posted on or by the telephone in the memory care nurse's desk area.”

“A smoke detector near a resident room was dangling from the ceiling by its wires, creating a hazard and indicating the furniture/equipment was not in good repair.”

“The gate door and keypad in the memory care courtyard marked as an emergency fire exit was inoperable, with the keypad providing no feedback and the door remaining locked. The facility reported the exit had been inoperable for at least 2 weeks, blocking unobstructed egress.”

“Poisonous materials (Procare vitamin A & D ointment labeled with Poison Control warning) were kept in an unlocked, unattended cabinet under a bathroom sink in the secured dementia care unit, accessible to residents. Not all residents have been assessed as capable of safely using or avoiding poisonous materials.”

“Multiple medication blister packs with punctured foil were observed in medication carts with medications still present, exposing them to contamination and improper sanitation conditions.”

“Resident in Secured Dementia Care Unit (SDCU) eloped twice by removing windows from unoccupied rooms. On the night of the incident, with only one direct care staff supervising 9 residents, the resident successfully eloped around 12:45 AM by removing a window, was missing for approximately 1.5 hours in 33°F weather wearing only a long sleeve shirt and pants, and was found by police with a scratch/skin tear on left ear and signs of cold exposure. This constitutes neglect due to inadequate supervision.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. Staff member had a foreign high school diploma which is not acceptable.”

“Resident supervision needs could not be met due to lack of additional direct care staffing. At the time of the elopement incident, only one direct care staff was present on the SDCU responsible for 9 other residents, all of whom have mobility needs and require assistance to evacuate in an emergency.”

“During the night shift from 11:00 PM to 07:00 AM, only 1 staff person present in the home was certified in first aid/CPR, which is insufficient for the number of residents requiring at least one certified staff person for every 50 residents.”

“The resident-home contract was not signed by the resident upon admission to the personal care home.”

“Two residents with extensive supervision needs eloped from the Memory Care Unit on separate dates. The facility failed to provide adequate supervision and security, as exit door alarms were not sufficiently audible to alert staff in all areas of the unit, and only one staff member was assigned to the overnight shift despite residents' need for regular supervision.”

“The alarm of the exit door in the Memory Care Unit demonstrated insufficient volume and was unable to be heard from the opposite side of the unit, presenting a safety hazard for resident elopement prevention.”

“Two residents' support plans were not revised after elopement incidents that indicated a change in the residents' needs.”

“The assessor did not sign and date the support plan for a resident who participated in the development of the support plan.”