Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holland Home Breton Rehabilitation & Living Centre during CMS and state inspections, most recent first.
Dignity and Dining Practices: Staff used the term “feeder” to describe residents who needed eating assistance, including while residents with dementia or cognitive impairment were within hearing distance. In addition, several cognitively impaired residents receiving meal supervision or hands-on assistance were served breakfast on trays in the dining room, and the DSM and DON stated there was no set reason or resident preference for meals to remain on trays.
Care plan not revised for increased transfer assistance needs. A resident with dementia, repeated falls, weakness, and difficulty walking had an MDS showing substantial/max assist for standing and all transfers, but the care plan and Kardex still reflected 1-assist transfers and did not include 2-person bed-to-chair transfer support or individualized interventions for fluctuating function. Staff were observed transferring the resident without consistent use of a gait belt or other supports, while an RN and PT stated the resident required 2 staff for transfers and was high risk for falls.
A resident with dementia, repeated falls, weakness, difficulty walking, and a high fall risk was observed being transferred in ways that did not match documented needs. Staff lifted the resident from bed and toilet without proper cueing, and at times without a gait belt or non-skid socks, while the resident did not bear weight. The care plan and Kardex did not reflect therapy’s recommendation for 2-person assist for all transfers, despite PT notes showing max A of 2 was needed.
Failure to use EBP during resident care. A resident with an indwelling urinary catheter and a stage 4 sacral pressure ulcer required EBP for high-contact care, but staff repeatedly provided transfers, toileting, incontinence care, and catheter-related care without proper gown and glove use. Staff were observed transferring the resident, handling wound dressings, and moving the resident into the hallway without consistent PPE use or hand hygiene, despite posted EBP instructions and the DON’s expectation that gown and gloves be worn for direct care.
A resident with an indwelling catheter experienced discomfort and a catheter-associated urinary tract infection due to improper handling of the catheter bag, which was often found resting directly on the floor without a barrier. Despite staff awareness of proper protocols, the facility failed to maintain the catheter equipment in a secured and sanitary manner, leading to pain and potential for further infections.
Dignity and Dining Practices
Penalty
Summary
The facility failed to consistently use dignified terms for residents and failed to ensure consistent dignified dining experiences for 10 of 45 residents reviewed for dignity. The deficiency involved residents who required eating assistance or supervision and included residents with dementia or cognitive impairment. The report states that the use of the term “feeder” was used by staff to describe residents who needed help with meals, and that this term was heard by residents who were within hearing distance and unable to respond meaningfully because of confusion or cognitive impairment. For one resident with dementia and severe cognitive impairment, a CNA was heard in the hallway outside the resident’s room stating that the resident was a “feeder” and that there were other feeders in the dining room who needed assistance. For two other residents, one with severe cognitive impairment and one with moderate cognitive impairment, a CNA told an RN in the hallway just outside their rooms that one resident was “a feeder,” and both residents were in their rooms with doors open and within hearing distance. The CNA later reported that “feeder” was the term she had used to describe residents who required eating and drinking assistance and that she had not known another term to use. The report also describes seven residents in an activity/dining room across from the nurse’s station who appeared cognitively impaired and received meal supervision, total dining assistance, or partial dining assistance. Their meals were served on trays on top of the dining tables, and the meals remained on the trays for the duration of breakfast. The Dining Services Manager and the DON both stated these residents needed more attention and feeding assistance, and both reported there was no set reason or resident group preference for meals to be served on trays in the dining room. The facility’s Resident Rights policy stated residents have the right to a dignified existence, and the Meal Delivery policy stated meal delivery should ensure a dignified dining atmosphere.
Care Plan Not Updated for Increased Transfer Assistance
Penalty
Summary
The facility failed to keep Resident #6’s comprehensive care plan revised to reflect an increased need for assistance with transfers. Resident #6 was admitted with diagnoses including dementia, repeated falls, unsteadiness on feet, weakness, and difficulty walking. A significant change MDS assessment showed the resident required substantial/maximal assistance to stand and for all transfers, and the care plan had been revised for increased assistance with bed mobility and toilet use, but it did not include 2-person assistance for bed-to-chair transfers or personalized interventions for the resident’s inconsistent functional abilities. Record review showed the Kardex still directed 1 assist for transfers. During observation, CNA D transferred the resident from bed to wheelchair and later from toilet to wheelchair, while RN L stated the resident did not stand well and it takes 2 people to transfer her. RN L was also observed lifting the resident during the toilet transfer, and the resident did not bear weight on her feet. On another observation, CNA M transferred the resident from bed to wheelchair without a gait belt or enabler bar and without cueing the resident before the transfer. Additional interviews and therapy records showed the resident’s transfer ability had declined and fluctuated. CNA M stated the resident had recently started not standing on her legs as she had before. PT V reported the resident was a max assist requiring 2 staff and identified her as high risk for falling, requiring 2 people, a gait belt, non-skid socks, and a wheelchair close by for all transfers. Therapy notes documented max assist of 2 for functional transfers and mobility, while NM F stated the resident’s functional abilities fluctuated and that the care plan should be updated when decline was identified, but she was not sure whether recent therapy communication had been received.
Unsafe Transfers and Care Plan Not Updated for Changing Transfer Needs
Penalty
Summary
The facility failed to ensure safe transfers were performed for a resident with dementia, repeated falls, unsteadiness, weakness, difficulty walking, and a stage 4 sacral pressure ulcer. The resident’s MDS showed substantial to maximal assistance was needed for standing and all transfers, and the fall risk evaluation identified the resident as high risk with a score of 17. The care plan and Kardex listed transfer assistance, but the care plan revisions did not include 2-person assistance for bed-to-chair transfers and did not reflect the resident’s inconsistent functional abilities. During observation, staff transferred the resident in ways that did not match the resident’s documented needs. One CNA transferred the resident from bed to wheelchair by lifting her without cueing her to stand or place her feet on the floor, while the resident wore thick socks with minimal grip and did not bear weight. In another observation, an RN lifted the resident off the toilet while a CNA pulled up the resident’s pants, and the resident’s legs were bent and she did not bear weight. On a separate observation, a CNA lifted the resident from the bed to the wheelchair without using a gait belt or enabler bar and without cueing the resident, and the resident was not wearing socks. Staff interviews and therapy notes showed conflicting understanding of the resident’s transfer status. An RN stated the resident did not stand well and it took 2 people to transfer her, while another RN said the resident could still be transferred by one person because she was light weight. Therapy documentation described the resident as requiring max assist of 2 for sit-to-stand and functional transfers, and the PT stated the resident required 2 people, a gait belt, non-skid socks, and a wheelchair close by for all transfers. The DON reported staff were expected to use a gait belt with all transfers and was not aware the resident was not bearing weight, while the NM stated the resident’s abilities fluctuated and that if the resident was not bearing weight, staff needed to get a second person.
Failure to Use EBP During Resident Care
Penalty
Summary
The facility failed to effectively implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter and a stage 4 sacral pressure ulcer. Resident #6 was admitted with dementia, a stage 4 pressure ulcer of the coccyx, and an indwelling catheter ordered due to urinary retention and wound contamination. The resident’s care plan identified the indwelling catheter, and the room had a sign directing staff to use EBP for high-contact activities including transferring, hygiene, changing briefs, catheter care, and wound care. During an observation, CNA D entered the resident’s room to transfer the resident from bed to wheelchair without putting on a gown or gloves. Later, while the resident was on the toilet, NM F and CNA D were present without gowns, and RN L entered the bathroom without a gown. RN L lifted the resident off the toilet and placed her in the wheelchair. CNA D removed gloves and pushed the resident into the hallway without performing hand hygiene, then applied the footrest and chair alarm. On another observation, DON B was completing wound care while the resident’s stage 4 coccyx wound, multiple wounds on the legs and feet, and urinary catheter were present. CNA M donned a gown and gloves, changed the catheter bag, provided cleansing and brief care, dressed the resident, and then transferred her to the wheelchair while keeping the same gloves on. CNA M touched the resident’s wound bandage with soiled gloves, removed gloves without hand hygiene, and exited the room wearing the gown until removing it in the hallway. CNA M reported she did not remove gloves until after the resident was in the wheelchair and should have discarded the gown in the bathroom. DON B stated staff were expected to wear a gown and gloves before providing direct care, including incontinence care and transfers.
Failure to Maintain Sanitary Catheter Care
Penalty
Summary
The facility failed to maintain urinary catheter equipment in a secured and sanitary manner for Resident #36, who was cognitively intact and had a primary diagnosis of urinary retention with an atonic bladder. The resident had an indwelling urethral catheter, and observations revealed that the urinary catheter bag was often resting directly on the floor without a barrier, contrary to infection control protocols. This improper handling of the catheter bag was confirmed by the resident, who reported that the bag frequently ended up on the floor, causing discomfort and pain at the catheter insertion site. During multiple observations, the catheter bag was seen lying directly on the floor, and staff did not take action to correct this during their visits to the resident's room. Interviews with staff, including a Certified Nurse Aide and the Director of Nursing, confirmed that the catheter bag should not be on the floor and should be placed in a privacy bag or on a barrier to prevent tension and potential infection. The resident reported experiencing pain due to the catheter bag's position, which was exacerbated by the leg strap riding down his leg, causing tension on the catheter. The resident had a recent catheter-associated urinary tract infection (CAUTI), with symptoms including gross hematuria and discomfort at the catheter site. The facility's policy on catheter usage and care, as well as CDC guidelines, emphasize the importance of keeping the catheter bag off the floor to prevent infections. Despite these guidelines, the facility's failure to adhere to proper catheter care protocols resulted in discomfort and the potential for further infections for Resident #36.
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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 Grand Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corewell Health Rehabilitation & Nursing Center - | 1.3 mi | ★★★★★ | 0 | 0 |
| Optalis Health And Rehabilitation Of Grand Rapids | 1.8 mi | ★★★★★ | 32 | 3 |
| Optalis Health & Rehabilitation At Kent-crossing | 2.8 mi | ★★★★★ | 33 | 0 |
| Holland Home - Raybrook Manor | 2.9 mi | ★★★★★ | 14 | 1 |
| Beacon Hill At Eastgate | 3.7 mi | — | 0 | 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 October 2026) and official state health department websites.