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 The Inn At Freedom Village during CMS and state inspections, most recent first.
Medication administration and assessment orders were not followed for residents with CHF. A resident received clonidine without a BP reassessment before the dose, and three residents had significant weight gains that were not reported to the physician despite daily weight notification orders. The DON confirmed the missed BP reassessment and lack of physician notification.
The facility's kitchen equipment and facilities were not maintained in proper working order, affecting food safety. Issues included a lack of paper towels at a hand sink, a dirty refrigerator, a non-functional cooler, plumbing problems, and a leaking spray arm. Additionally, the Walk-In Freezer had buckling flooring, and a door to the dumpster area had a gap, potentially allowing pest entry.
A resident with multiple diagnoses, including hypertensive chronic kidney disease, had an order for Midodrine HCl to be given twice daily unless systolic blood pressure exceeded 140 mmHg. On a specific day, the medication was withheld due to a supposed out-of-parameter vital sign, but the only recorded blood pressure was 133/72 mmHg, which was within the acceptable range. The Director of Nursing confirmed the medication could have been administered and acknowledged the need for proper documentation of vital signs.
A facility failed to implement its Hot Liquid Protocol for a resident at risk for hot liquid injuries due to tremors and weakness in the upper extremities. The resident was observed drinking coffee in bed without a lid, clothing protector, or wrist splint, contrary to the care plan. The DON confirmed that staff are expected to follow the care plan and protocol.
Medication Administration and Weight Notification Orders Not Followed
Penalty
Summary
The facility failed to ensure medications were administered and assessments were completed in accordance with physician orders for 3 of 12 residents reviewed. For one resident with congestive heart failure, clonidine 0.1 mg was ordered three times daily with instructions to hold if systolic BP was less than 110, but the resident’s BP was not reassessed prior to the 2:00 PM dose on 2 occasions. The MAR documented earlier BP readings were used for those administrations, and the medication was given despite no same-time reassessment. The RN stated that vital signs are to be assessed prior to administering a medication when parameters are ordered. The same resident also had a daily weight order to notify med staff of a 2 lb gain in 24 hours or 5 lb in 1 week, but after a weight increase from 144.6 lbs to 148.4 lbs, the physician was not notified. Two other residents with congestive heart failure had similar daily weight orders, and their records showed weight gains of approximately 7.5 lbs, 3.5 lbs, and 4 lbs on separate dates without physician notification. The DON confirmed the BP was not reassessed prior to clonidine administration and that the physician was not notified of the weight increases for the three residents.
Kitchen Equipment and Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its kitchen and equipment in proper working order, potentially affecting all residents receiving food from the kitchen. During an inspection, it was observed that the paper towel dispenser above the hand sink was out of paper towels, violating the FDA 2017 Food Code requirement for handwashing sinks to be equipped with disposable towels. Additionally, the True Refrigerator Unit had a build-up of food residue and grime, and the large 2 Door Cooler was out of order, which is essential for cold food storage. The hand sink in the dishwashing area required recaulking to the wall, and the plumbing system in the 3 Compartment Sink Area was not properly attached, posing a risk of back-siphonage due to a worn spray arm hose. Further observations revealed that the dish machine area had a continuous hot water leak from the spray arm fixture, and the Walk-In Freezer had flooring issues with buckling seams. The door leading to the dumpster area had a large gap at the bottom, which could allow the entry of insects and rodents, contrary to the FDA Food Code requirements. These deficiencies indicate a lack of adherence to the FDA 2017 Food Code standards, which require equipment and facilities to be maintained in good repair to ensure safe food service operations.
Failure to Document Vital Signs Before Withholding Medication
Penalty
Summary
The facility failed to document vital signs before withholding a medication with specific parameters for a resident. The resident, who was admitted with diagnoses including hypertensive chronic kidney disease, supraventricular tachycardia, and nonrheumatic mitral valve insufficiency, had an order for Midodrine HCl to be administered twice daily for low blood pressure, with instructions to hold the medication if the systolic blood pressure exceeded 140 mmHg. On the specified date, the resident did not receive the medication at the scheduled times, as indicated by a notation in the medication administration record that vital signs were out of parameter. However, a review of the blood pressure summary for that day showed a recorded blood pressure of 133/72 mmHg, which was within the acceptable range for administering the medication. No other blood pressure readings were documented for that day, and the progress notes did not reflect any blood pressures exceeding the physician's parameters. During an interview, the Director of Nursing confirmed that the recorded blood pressure would have allowed for the medication to be given as ordered and acknowledged the professional standard requiring documentation of vital signs when parameters are set by the physician.
Failure to Implement Hot Liquid Protocol for At-Risk Resident
Penalty
Summary
The facility failed to implement its Hot Liquid Protocol for a resident at risk for injury from hot liquids. Resident #85, who was admitted for rehabilitation and had observed tremors and weakness in the upper extremities, was identified as being at risk for hot liquid injuries. The care plan for this resident included interventions such as assisting with hot liquids, using a cup with a lid, wearing a splint for wrist stability, and using a clothing/lap protector. However, during an observation, the resident was given a cup of coffee by a dietary aide while in bed, without a lid, and was drinking it with a straw. The resident did not have a clothing protector or wrist splint in place, contrary to the care plan and the facility's Safety of Hot Liquids policy. The Director of Nursing confirmed that the expectation was for all staff to follow the care plan and hot liquid protocol.
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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 Holland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Holland | 2.3 mi | ★★★★★ | 4 | 0 |
| Resthaven Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Zeeland | 4.4 mi | ★★★★★ | 6 | 0 |
| Heritage Nursing And Rehabilitation Community | 4.7 mi | ★★★★★ | 19 | 0 |
| The Orchards At Douglas Cove | 12.1 mi | ★★★★★ | 5 | 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.