Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
Food service staff failed to consistently date mark ready-to-eat TCS foods and opened items in the kitchen and resident refrigerator. An open container of thickened water, an open cranberry cocktail, beef barley soup, and egg salad were found without proper or consistent date markings, and staff reported there was no specific written procedure for how to date food for holding.
Employee illness surveillance practices were not fully implemented when illness-related staff call-ins were not consistently entered on the EITL. An LPN and a CNA reported symptoms including vomiting, diarrhea, cramps, bloating, and a GI virus, but several of those call-ins were not tracked, and one CNA call-in had no illness explanation documented. The ICP/DON stated she reviewed call-in forms and decided which ones to place on the EITL based on symptoms reported.
Unsafe Sit-to-Stand Lift Transfer: A resident with morbid obesity, cognitive communication deficit, weakness, unsteadiness on feet, and reduced mobility was care planned for 2-person assistance with toileting and transfers using a sit-to-stand lift. During observation, one CNA transferred the resident alone from the toilet, did not secure the middle safety strap, and moved her to a chair. Staff interviews confirmed that sit-to-stand and other mechanical lift transfers require 2 staff for safety, and the resident stated that sometimes only one staff member transfers her off the toilet.
The facility's kitchen failed to adhere to food safety standards, with improper cooling of leftovers, inadequate dishwashing temperatures, and poor sanitation practices. Equipment and utensils were found with grease deposits, and an open Teriyaki marinade was improperly stored. These deficiencies risk foodborne illness for residents.
A facility failed to honor a resident's advanced directives by allowing a patient advocate to make medical decisions despite the resident being cognitively intact. The advocate signed a Medical Treatment Decisions form and a Do-Not-Resuscitate Order, although they were only authorized to act if the resident was incapacitated. The resident was not deemed incapacitated until two months after admission, highlighting the facility's oversight in respecting the resident's decision-making rights.
A LTC facility failed to administer medications according to professional standards for three residents, leading to medication errors and withholding without physician orders. A resident with diabetes had insulin withheld due to low blood sugar without a physician's directive. Another resident received a reduced insulin dose without documentation of a provider's order. A third resident's hypertension medication was withheld based on non-existent parameters, and the physician was not notified. The DON confirmed these deficiencies.
The facility failed to properly administer and document controlled substances for three residents, leading to potential issues in pain management and drug diversion. A resident with anxiety and spinal stenosis had discrepancies in her medication records for Norco and Ativan. Another resident with a history of fractures had multiple instances of undocumented oxycodone administration. A third resident also had oxycodone administration discrepancies. The DON confirmed these errors, highlighting a failure to adhere to the facility's documentation policy.
The facility failed to involve residents or their representatives in medication management and did not adequately monitor the effects of gradual dose reductions (GDR) of psychotropic medications for two residents. One resident experienced increased aggression after a Paxil reduction, while another had a Depakote reduction without proper consent. The facility did not adhere to its policy of educating representatives on medication risks and benefits.
A resident admitted with metabolic encephalopathy was assessed as lacking capacity for medical decision-making. The hospitalist's assessment was signed by the facility's MD without a date or documented agreement, leading to an incomplete medical record.
A facility failed to properly explain an arbitration agreement to a resident's HCPOA, resulting in a lack of understanding of the terms. The HCPOA signed the agreement without realizing the implications and the option to cancel within 30 days. The NHA sent the agreement digitally, allowing insufficient time for thorough review, and did not ensure the agreement was witnessed, leading to a deficiency.
Food Items Stored Without Proper Date Marking
Penalty
Summary
The facility failed to maintain best practices in the food service area by allowing multiple food items to be stored without proper date marking and by using inconsistent methods for dating food held for later use. On 03/15/2026 at 8:55 AM, an open container of thickened water was observed in the residents' refrigerator without an open date or facility-provided use-by date. Dietary staff stated that the thickened water should have had a date on it and that nursing staff is responsible for dating product used for med-pass and resident food. The container was discarded by the dietary staff member. Additional observations in the walk-in cooler showed an open container of Ready Care Cranberry Cocktail without an open date or use-by date, along with beef barley soup dated 3/9 with a use-by date of 3/12 and egg salad dated 3/9 with a use-by date of 3/13. When asked about the policy for date marking time/temperature controlled for safety food, dietary staff stated each staff member used an individual method and there was no specific written procedure for how to date food for holding. The Certified Dietary Manager later stated the egg salad and beef barley soup were dated incorrectly and should have been marked with a seven-day use-by date, and also stated responsibility for removing expired items from the refrigerator.
Employee illness call-ins were not consistently tracked on the EITL
Penalty
Summary
The facility failed to fully implement its employee illness surveillance practices when employee illness call-ins were not consistently tracked on the Employee Illness Tracking Log (EITL). During interview, the Infection Control Preventionist/Director of Nursing stated that illness-related employee call-ins were placed on the EITL, that the most recent entry was dated 1/2/26, and that there had been no illness-related call-ins in February or March. She also stated that employee call-in forms were generated by the staff person taking the call, given to employee H for filing, and that she received copies of the forms and decided which ones should be entered on the EITL based on symptoms reported at the time of the call-in. Review of employee call-in forms showed multiple illness-related absences that were not placed on the EITL for monitoring and tracking. An LPN called in sick and reported vomiting, but the call-in was not entered on the EITL. A CNA called in sick with no explanation or illness description documented on the form. The same CNA also called in sick on two other occasions and reported vomiting and diarrhea, but those call-ins were not placed on the EITL. Another LPN called in sick and reported cramps, bloating, diarrhea, and a GI virus, and that call-in was also not placed on the EITL. The facility policy stated that employee illness symptoms were to be recorded on the Employee Call In Form, reported to the ICP/DON, and also tracked on the EITL for real-time tracking of illness.
Unsafe Sit-to-Stand Lift Transfer
Penalty
Summary
The facility failed to safely transfer one resident who had diagnoses of morbid obesity, cognitive communication deficit, weakness, unsteadiness on feet, need for assistance with personal care, and reduced mobility. The resident’s care plan directed staff to assist with toileting/elimination needs with 2 staff persons and to assist with transfers with 2 staff persons using a sit-to-stand lift. During observation, one CNA entered the room alone and used the mechanical sit-to-stand lift to lift the resident off the toilet, did not secure the middle safety strap, and transferred the resident to the chair. On another observation, two CNAs entered to assist the resident while she was on the toilet with the sit-to-stand lift in front of her and the call light on. Staff interviews indicated that residents using a sit-to-stand lift require 2 staff persons for safe transfer, and a COTA stated that all transfers made with mechanical lifts require 2 staff persons for safety reasons. The resident stated that sometimes only one staff person transfers her off the toilet with the sit-to-stand lift.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards for food service safety, as observed during a kitchen tour. A handwashing sink was obstructed by a chemical container, and leftover scrambled eggs in the walk-in cooler were found warm to the touch, indicating improper cooling. The Dietary Manager (DM) reported that foods cooled for reuse are documented on a cooling log, but there was no documentation for the leftover foods found. The scrambled eggs and sausage links were not cooled to the required temperatures within the specified time, as per the FDA Food Code. Further observations revealed issues with the facility's dishwashing practices. The low-temperature dish machine did not reach the required 120 degrees Fahrenheit during the wash and rinse cycles, and the chemical sanitizer concentration was below the necessary level. The Dish Machine Temperature Log showed consistent failures to meet the required temperatures during various meal services. Additionally, the DM's calibration of thermometers indicated inaccuracies in food temperature measurements, further compromising food safety. The facility also exhibited poor sanitation practices, with equipment and utensils showing encrusted grease deposits and debris. An open container of Teriyaki marinade was improperly stored in the dry storage room, despite the manufacturer's label indicating it should be refrigerated after opening. These deficiencies in food handling, storage, and equipment sanitation pose a risk of foodborne illness to residents consuming food from the facility's kitchen.
Failure to Honor Resident's Advanced Directives
Penalty
Summary
The facility failed to honor the advanced directives of a resident, identified as R2, who was cognitively intact upon admission, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13/15. Despite this, the facility allowed a patient advocate to make medical treatment decisions on behalf of R2, even though the advocate was only authorized to act if R2 was unable to make decisions themselves. This was evident in the signing of a Medical Treatment Decisions form and a Do-Not-Resuscitate Order by the patient advocate, rather than R2, who was capable of making their own medical decisions at the time. The deficiency was further highlighted by the fact that R2 was not deemed incapacitated until two months after admission, as determined by evaluations from two physicians. The Social Services staff confirmed that R2 had not been declared incapacitated at the time the forms were completed, indicating a failure by the facility to ensure that the resident's rights to make their own medical decisions were respected. This oversight resulted in the patient advocate inappropriately signing critical medical documents on behalf of R2.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to nursing professional standards of practice for three residents, resulting in medication errors and the withholding of medications without a physician order. Resident #35, a male with type 2 diabetes, had his insulin aspart withheld on two occasions due to low blood sugar levels, despite no physician order to hold the medication under such circumstances. There was no documentation indicating that the licensed nurse received an order to hold the insulin or that the provider was notified of the non-administration. Resident #11, a female with diabetes, was administered only 15 units of Lantus insulin on two separate occasions, contrary to the ordered 30 units. There was no documentation of a provider order for the decreased dose or a rationale for the administration of the incorrect dose. Resident #30, a male with hypertension, had his metoprolol withheld due to perceived parameters that were not present in the order. The nurse did not contact the physician to inform them of the withheld medication or to clarify the order. The Director of Nursing confirmed these deficiencies and reported that licensed nurses should not make medication decisions without consulting the provider.
Controlled Substance Administration and Documentation Errors
Penalty
Summary
The facility failed to properly administer and document the administration of controlled substances for three residents, leading to potential issues in pain management and drug diversion. Resident #17, a female with anxiety, spinal stenosis, and severe osteopenia, had discrepancies in the administration records for hydrocodone-acetaminophen and lorazepam. On a specific date, her evening dose of Norco was not documented as administered, and there was no record of her Ativan being removed or administered, despite being documented as administered in the Medication Administration Record. There was no documentation or rationale provided for withholding these medications. Resident #16, a male with a history of pelvic and rib fractures, had multiple instances where oxycodone was documented as being pulled/administered, but not recorded in the Medication Administration Record. Similarly, Resident #239, a male with unspecified diagnoses, had oxycodone documented as pulled/administered on two occasions, but these were not reflected in the Medication Administration Record. The Director of Nursing confirmed these documentation errors and noted that licensed nurses are required to document controlled drug administration at the time of administration. The facility's policy mandates additional documentation for PRN medications, which was not adhered to in these cases.
Failure in Medication Management and GDR Monitoring
Penalty
Summary
The facility failed to involve residents or their representatives in the medication management process and did not adequately evaluate and track progress towards the gradual dose reduction (GDR) of psychotropic medications for two residents. Resident #4, a female with dementia and major depressive disorder, had her Paxil dosage reduced without proper consultation with her Durable Power of Attorney (DPOA). The reduction led to increased aggressive behaviors, which were not adequately monitored or documented by the Behavior Management Team. The team also failed to review or discuss the increased aggression and resident-to-resident abuse incidents that occurred following the GDR. Resident #24, a male with vascular dementia and agitation, experienced a GDR of Depakote following a fall, without proper notification or consent from his DPOA. The DPOA was not informed of the risks and benefits of the GDR, nor was there documentation of their consent. The facility's policy required resident representatives to be educated on the risks and benefits of psychotropic medication use, but this was not adhered to in the case of Resident #24. The facility's failure to involve resident representatives in the medication management process and to adequately monitor and document the effects of GDRs led to deficiencies in care. The lack of communication and documentation regarding the residents' increased behaviors and the absence of proper consent for medication changes contributed to the facility's non-compliance with state regulations.
Incomplete Medical Record for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted from a hospital with a diagnosis of metabolic encephalopathy. The resident was assessed as moderately cognitively impaired with a BIMS score of 10/15. A hospitalist's progress note indicated that the resident lacked the capacity to make informed decisions regarding complex medical matters and recommended the activation of a medical durable power of attorney (MDPOA). This assessment was electronically signed by the hospital physician. However, the facility's Medical Director (MD) signed the document without dating it or providing a documented assessment or statement of agreement with the hospital physician's evaluation. During an interview, the MD acknowledged signing the document but could not recall when it was signed, indicating an intention to agree with the assessment of capacity. This lack of documentation and clarity in the medical record constitutes a deficiency in maintaining accurate and complete records in accordance with professional standards.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to adequately explain the terms of an Agreement to Resolve Legal Disputes Through Arbitration to the Health Care Power of Attorney (HCPOA) for a resident, identified as R29, and did not ensure that the understanding and consent to enter into the agreement were properly witnessed. R29 was admitted to the facility with a diagnosis of metabolic encephalopathy. The arbitration agreement was signed by the HCPOA and the Nursing Home Administrator (NHA) without the resident's name filled in and without a witness signature. During an interview, the HCPOA expressed a lack of understanding of the arbitration agreement, stating he was overwhelmed during the admission process and unaware of the option to cancel the agreement within 30 days. The NHA reported being surprised by the HCPOA's lack of understanding and provided email communication as evidence of the agreement process. The email history showed that the NHA sent a digital envelope containing 30 documents, including the arbitration agreement, to the HCPOA, who signed it 13 minutes after opening it. This timeframe allowed only 43 seconds per document, suggesting inadequate review. The NHA claimed to have discussed the agreement with the HCPOA over the phone and offered to answer any questions, but the HCPOA did not indicate any confusion at that time. The deficiency was identified due to the lack of proper explanation and witnessing of the arbitration agreement, leading to the HCPOA's misunderstanding of the terms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Zeeland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Zeeland | 0.6 mi | ★★★★★ | 6 | 0 |
| Medilodge Of Holland | 3 mi | ★★★★★ | 4 | 0 |
| The Inn At Freedom Village | 4.7 mi | ★★★★★ | 3 | 0 |
| Resthaven Care Center | 6.6 mi | ★★★★★ | 0 | 0 |
| The Oaks At Jamestown | 8 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.