Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Lutheran Village At Wolfcreek during CMS and state inspections, most recent first.
A facility failed to ensure medications and biologicals were properly dated and discarded after expiration. During observation with an RN, an opened bottle of Geri-Lanta was found expired on the shelf, and an opened bottle of Tuberculin PPD in the med refrigerator was found undated. The RN confirmed both findings, and facility documents stated that date-sensitive meds must be dated when opened and that PPD must be discarded 30 days after opening.
Oxygen tubing was not changed or labeled as required, and oxygen was not administered at the ordered rate for four residents receiving O2 therapy. One resident had stiff, yellowed tubing with no change date, another had tubing on the floor and a cannula not on the nose, a third had undated tubing, and a fourth was receiving O2 at 2.5 L/min instead of the ordered 2 L/min. An LPN verified the missing tubing dates and the incorrect O2 flow rate.
Staff failed to follow infection control practices during resident care. An RN administered insulin without disinfecting the insulin pen tip first, an LPN used the same BP cuff on two residents on EBP without cleaning it between uses, a CNA provided high-contact care to a resident on EBP without PPE, and another RN performed g-tube care without hand hygiene or an isolation gown. The residents involved had conditions including DM, ESRD, indwelling catheters, chronic wounds, a g-tube, and MDR organism status.
Code status was not documented consistently across the EHR for two residents. One resident had a signed DNR-CC form in the paper chart, but no corresponding physician order was initially present in the EHR; another resident had no code status order in the EHR at all. The DON confirmed the EHR migration issue affected code status information, and facility policy stated preferred code status should be documented in the medical record.
A resident with moderate cognitive impairment and a primary language of Chinese was unable to communicate needs consistently because staff relied on her husband to translate and had no known translation devices or communication tools. The resident could not speak English, staff could not determine her needs when her husband was absent, and a CNA reported an episode where the resident used her call light but staff could not understand that she needed help using the telephone to call her husband.
Inadequate Oral Hygiene Assistance for a Dependent Resident: A cognitively intact resident who was dependent on staff for all ADLs, including oral care, did not receive oral hygiene as directed in the care plan. CNA documentation showed oral care was not provided daily, and the resident reported that his teeth were sometimes not brushed at all. Staff interviews confirmed the resident required total assistance and that some staff were unfamiliar with his care needs.
Failure to apply ordered heel protectors for a resident with multiple heel pressure ulcers. The resident had severe cognitive impairment, was dependent for most ADLs, and had stage 4, stage 3, and stage 2 heel wounds being followed by wound clinic. Surveyors observed the resident in bed and in a wheelchair without the ordered pressure-relieving boots in place or with only one boot, and staff confirmed the resident did not always have both boots on despite physician orders for heel boots to both lower extremities and skin checks each shift.
Fall Intervention Not In Place as Ordered: A resident with CHF who was cognitively impaired and at risk for falls had an order and care plan for shorter oxygen tubing as a fall intervention, but observation showed green extension oxygen tubing approximately 25 feet long in use. An LPN verified the tubing length, and the DON stated the resident had tripped over the long tubing; the facility policy stated the resident would be observed to ensure new interventions were in place.
Medication was not administered per the physician's order for a resident receiving midodrine for hypotension. The resident had multiple chronic conditions and an order for midodrine without hold parameters, yet the MAR showed several held doses and an LPN withheld a dose when the BP was 120/51 mmHg. The LPN and DON stated there was an assumed BP threshold for holding the medication, but no documented parameters were in place at the time.
Expired and Undated Medications Found in Storage
Penalty
Summary
The facility failed to ensure medications and biologicals were properly dated and discarded after expiration. During observation of the medication storage room with RN #682, a bottle of Geri-Lanta was found on the shelf opened with an expiration date, and a bottle of Tuberculin purified protein derivative (PPD) in the medication refrigerator was found opened and undated. RN #682 verified that the Geri-Lanta was opened and expired and confirmed the Tuberculin PPD was opened and undated, stating that the PPD should be dated and initialed when opened. Review of the facility’s medication expiration list and package insert for Tuberculin PPD showed that the PPD should be discarded 30 days after opening, and the facility policy stated that staff must date all date-sensitive medications upon opening.
Oxygen tubing not changed or labeled and oxygen rate not set as ordered
Penalty
Summary
The facility failed to ensure oxygen tubing was changed and labeled as required and failed to ensure oxygen was administered at the ordered rate for four residents receiving oxygen therapy. Facility policy titled, Oxygen Administration, stated oxygen should be turned on to the prescribed amount and the oxygen tubing should be changed and labeled monthly and as needed. Resident #20 had diagnoses including pulmonary embolism, COPD, osteoarthritis, anxiety disorder, morbid obesity, depression, and polyneuropathy, and was cognitively intact. Her care plan included oxygen via nasal cannula at four liters. Her physician order required oxygen tubing and humidifier changes the first Wednesday of the month every night shift every four weeks. During interview and observation, her tubing was stiff, yellowed, and had no date or label showing when it had last been changed. An LPN verified the tubing was not dated or labeled and later placed tape with the date on it, but the tubing was not observed being changed. The resident later stated the tubing had not actually been changed. Resident #12 had COPD, peripheral vascular disease, type II diabetes, major depressive disorder, bipolar disorder, anxiety disorder, stroke, chronic pain, and hallucinations, and was severely cognitively impaired. He was ordered oxygen at two to four liters per nasal cannula every shift. Observation showed his oxygen tubing was partially on the floor and wrapped around the bed rail, with no label indicating when it had last been changed, and his nasal cannula was lying on his chest instead of being on his nose. Resident #21 had CHF and was cognitively impaired, with an order for oxygen tubing and humidifier changes the first Wednesday of every month; observation found no date on the tubing. Resident #39 had asthma and chronic respiratory failure, was cognitively intact, and had orders for oxygen at two liters per minute and for tubing and humidifier changes with dating and initials on the tubing; observation showed the oxygen was running at 2.5 liters per minute and the tubing was not dated. An LPN verified the incorrect oxygen rate for Resident #39 and confirmed the tubing for Residents #12, #20, and #21 was not dated.
Infection Control Failures During Resident Care
Penalty
Summary
Staff failed to follow infection prevention and control practices during resident care for multiple residents. Resident #1, who had end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic neuropathy, was receiving insulin aspart by sliding scale. During medication administration, RN #682 removed the insulin pen, placed the needle on it, and administered the insulin without disinfecting the end of the pen first. RN #682 confirmed she did not clean the insulin pen before attaching the needle, and manufacturer instructions and the facility’s insulin pen guide both required disinfecting the pen tip with alcohol before each use. Staff also failed to clean shared medical equipment between residents who required enhanced barrier precautions. Resident #41 had an indwelling urinary catheter and was identified for EBP, and Resident #19 had quadriplegia, a carbapenem-resistant enterobacter carrier status, neuromuscular bladder dysfunction, chronic wounds, and an indwelling urinary catheter, with EBP ordered for chronic wounds and the catheter. An LPN used the same wrist blood pressure cuff on Resident #41 and then on Resident #19 without cleaning or disinfecting it between uses. The LPN stated he did not clean the cuff and did not know it should be cleaned or how to clean it, and the DON confirmed the cuff was not disinfected between residents. In addition, staff did not use required PPE or perform hand hygiene during care for residents on EBP. A CNA provided morning care to Resident #19, including changing the incontinence brief, providing peri-care, assisting with hygiene and brushing teeth, and dressing the resident, without wearing PPE. For Resident #23, who had an active order for EBP related to a gastrostomy tube, an RN provided g-tube care without performing hand hygiene before care, between glove changes, or after removing gloves, and did not don an isolation gown. The RN confirmed the actions and stated she should have worn a gown and washed her hands before, between, and after resident care. Facility policies for EBP, hand hygiene, and cleaning/disinfection of resident-care equipment were reviewed and were not followed during these observed events.
Code Status Not Documented Consistently in EHR
Penalty
Summary
The facility failed to ensure resident code status was documented across all medical records for two residents sampled for record review. Resident #10 was admitted with diagnoses including Alzheimer's disease, noninfective gastroenteritis and colitis, type II diabetes mellitus, COPD, peptic ulcer disease, diverticulosis, iron deficiency anemia, and a history of multiple hospitalizations for GI bleed. Review of the paper medical record showed a signed DNR-CC form, but the EHR physician orders initially contained no code status order. The DON later verified that the DNR-CC order was not entered into the EHR until after the missing order was identified. Resident #36 was admitted with diagnoses including dementia, hypertension, hyperlipidemia, atherosclerotic heart disease, and heart valve replacement. Review of the EHR showed no code status orders for this resident, and an LPN confirmed the code status was not present and should have been. The DON stated the facility changed EHR software on 04/03/25 and was alerted on 07/11/25 that code status information did not migrate correctly. The DON also confirmed that code status should have been documented in two places in the EHR, on the landing page banner and in orders, and the facility policy titled Advance Directives stated physician orders for preferred code status would be documented in the medical record.
Failure to Provide Consistent Communication Support for a Non-English-Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident who was not able to speak English had a consistent means of communication for care needs. Resident #1 was admitted on 07/03/25 with diagnoses including end stage renal disease, dependence on renal dialysis, colostomy status, muscle weakness, and type II diabetes. The resident’s MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment. The resident’s preferred language was Chinese, and the care plan identified communication needs with interventions including a picture board for basic needs and use of the resident’s husband for translation. During the review, the resident was observed to rely on her husband for communication, and when asked questions she shook her head and pointed to him. Her husband confirmed she could not speak English and said he was only able to speak a little English, was available during the day to translate, and was not sure how staff communicated with her when he was not present. A CNA verified staff were not able to communicate with the resident when her husband was not there and reported there were no translation devices or communication tools she was aware of. The CNA also described an instance when the resident used her call light but staff could not determine what she needed until her husband later explained she had been trying to call him on the telephone and could not get the call to go through. The facility policy stated residents had the right to communicate in a dignified manner when unable to communicate due to language, hearing, or sight barriers.
Inadequate Oral Hygiene Assistance for Dependent Resident
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for all ADLs received adequate and timely oral hygiene. Resident #6 was admitted with diagnoses including fusion of the cervical spine, fracture of cervical vertebrae, fracture of tibia, pulmonary embolism, muscle wasting, and morbid obesity. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and the care plan directed that he had his own teeth and required assistance with oral care every shift. Review of CNA task documentation over the prior 30 days showed oral care was documented only on selected days, with no oral care documented on some days and one documented refusal on another day. During interview, the resident stated he was not getting his teeth brushed as often as he wanted, could not brush them himself, and that there were days his teeth were not brushed at all. CNA interviews confirmed the resident required total assistance with all ADLs, including brushing his teeth, and that care was documented when completed. One CNA stated that if care was not documented, it was not completed, and the documentation showed the resident’s teeth were not brushed daily. Additional CNAs stated they were unfamiliar with the resident’s care needs or how often his teeth were brushed when working on his hall. The facility policy required resident care plans to be followed daily for residents who required such services.
Failure to Apply Ordered Heel Protectors
Penalty
Summary
The facility failed to ensure interventions for prevention of pressure ulcers were applied as ordered for one resident with multiple existing wounds. The resident was admitted with dementia, COPD, Alzheimer’s disease, major depressive disorder, anxiety disorder, and pressure ulcers to both heels. The resident’s MDS showed severe cognitive impairment, dependence for most ADLs and transfers, maximal assistance with eating, and hospice services. The care plan included interventions for chronic wounds, turning and repositioning at least every two hours, a low air loss mattress, and weekly wound documentation. Physician orders included heel protector boots to be worn while in bed and later an order for heel boots to both lower extremities at all times as tolerated, with skin integrity monitoring every shift. Survey observations showed the resident was repeatedly without the ordered pressure-relieving devices or had only one boot in place. The resident was observed in bed with both heels flat on the mattress and no boots in place, later seated in a wheelchair with a sock on one foot and no pressure-relieving device on the other, and again in bed with only one boot on. Staff interviews confirmed the resident did not always have both boots on and that staff were aware of treatment orders for the heels. The resident’s wound clinic evaluations documented three heel wounds being followed—a stage four left heel wound, a stage three medial heel wound, and a stage two right lateral heel wound—all noted as improving. The facility policy stated that residents at high risk for pressure ulcers should have protective skin devices such as heel protectors implemented.
Fall Intervention Not In Place as Ordered
Penalty
Summary
The facility failed to ensure fall interventions were in place as ordered and care planned for Resident #21, who was admitted with CHF and was identified on the quarterly MDS as cognitively impaired and at risk for falls. The current physician orders from September 2025 included shorter oxygen tubing as a fall intervention, and the care plan revised on 08/27/25 also identified shorter oxygen tubing as an intervention for fall risk. On 09/02/25, observation of Resident #21 showed green oxygen tubing extension in use along with the nasal cannula tubing, with the oxygen concentrator placed in the farthest corner of the room from the bathroom and the tubing stretching into the shared bathroom and beyond. An LPN verified the resident had an order for shorter oxygen tubing and that approximately 25 feet of green extension tubing was in place. The DON later stated the resident had tripped over 25 feet of extension oxygen tubing and that the tubing at the time of the fall was 25 feet long, described as green tubing from hospice, while the facility tubing was clear and seven feet long.
Medication Held Without Ordered Parameters
Penalty
Summary
The facility failed to ensure medications were administered per physician's order for one resident who was reviewed for medication administration. The resident had diagnoses including malignant neoplasm of the rectum, malignant neoplasm of the prostate, chronic kidney disease, and hypertension, and later developed hypotension. A progress note documented a plan to continue midodrine for low blood pressure management, and a care plan addressed hypotension related to multiple co-morbidities with an intervention to give medications as ordered. A physician order dated 05/25/25 prescribed midodrine 10 mg by mouth three times daily with no blood pressure hold parameters. Review of the August 2025 MAR showed midodrine was held on multiple dates. During observation of medication administration, an LPN obtained a blood pressure of 120/51 mmHg and did not administer the midodrine. The LPN stated there were no parameters for the medication and that it was not given because the blood pressure was 120/51 mmHg. The DON stated there was an understanding that midodrine should be held if blood pressure was above 110 or 120 mmHg, but the facility could not produce documentation of standard blood pressure parameters for midodrine. The physician order later included hold parameters for systolic blood pressure greater than 120 mmHg or diastolic blood pressure greater than 80 mmHg.
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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) |
|---|---|---|---|---|
| Spring Meadows Nursing, A Villa Center | 1.3 mi | ★★★★★ | 10 | 0 |
| Ohio Living Swan Creek | 1.5 mi | ★★★★★ | 17 | 0 |
| Ridgewood Manor | 1.5 mi | ★★★★★ | 8 | 0 |
| Heatherdowns Rehab & Residential Care Center | 2.2 mi | ★★★★★ | 7 | 0 |
| Elizabeth Scott Community | 2.3 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 July 2026) and official state health department websites.