LUTHERAN HOME AT HOLLIDAYSBURG

916 HICKORY STREET, HOLLIDAYSBURG, PA 16648

Facility Assessment Inspectors recorded 2 citations at the actual-harm level or worse in the last three survey cycles.

At or above the 2024 benchmark — above average inspection record.

Quality Breakdown

RN Staffing Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.	0.85 — At or above the repealed 0.55 hr benchmark
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles) Violations found during federal inspections, with how many remain open and how many involved actual harm.	Total 39 Outstanding 0 Actual harm or worse (G–L) 2
CMS Ratings Overall and Staffing quality ratings from CMS (1-5 stars).	Quality: ★★★★☆ (4/5) Staffing: ★★★★☆ (4/5)
NursingHomeGrade Score	66/100

Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

2 actual harm issues found among 39 total deficiencies. 39 corrected.

Most recent inspection (December 10, 2025)

D Potential harm — isolated F0941 Status: Corrected

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0944 Status: Corrected

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

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0946 Status: Corrected

Provide training in compliance and ethics.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0949 Status: Corrected

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0943 Status: Corrected

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0945 Status: Corrected

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0730 Status: Corrected

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

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0947 Status: Corrected

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0760 Status: Corrected

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0684 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0655 Status: Corrected

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

D Potential harm — isolated F0942 Status: Corrected

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025

Inspection cycle 2 (September 12, 2024)

D Potential harm — isolated F0770 Status: Corrected

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

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 1, 2024

E Potential harm — pattern F0867 Status: Corrected

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 1, 2024

G Actual harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected June 24, 2024

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 1, 2024

D Potential harm — isolated F0729 Status: Corrected

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Nursing and Physician Services Deficiencies — Past Non-Compliance, corrected April 5, 2024

D Potential harm — isolated F0755 Status: Corrected

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

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 1, 2024

D Potential harm — isolated F0761 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 1, 2024

D Potential harm — isolated F0676 Status: Corrected

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.