Inspection Reports for Holland Home Breton Woods Rehabilitation & Living Centre
MI, 49512
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 1
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with appropriate care standards for residents with urinary catheters, specifically focusing on catheter care and prevention of urinary tract infections.
Findings
The facility failed to ensure urinary catheter equipment was consistently maintained in a secured and sanitary manner for Resident #36, resulting in discomfort, pain at the catheter insertion site, and potential for catheter-associated urinary tract infections. Observations showed the urinary catheter bag was frequently left on the floor without a barrier, causing tension and pain for the resident.
Deficiencies (1)
Failure to maintain urinary catheter equipment in a secured and sanitary manner, leading to discomfort and potential infections for Resident #36.
Report Facts
Resident mental status score: 15
Antibiotic treatment duration: 7
Pain level: 5
Colony-forming units per milliliter: 100000
Date of infection report: Mar 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Registered Nurse F provided medication to Resident #36 during observation | |
| Certified Nurse Aide | Certified Nurse Aide G reported catheter bags should not be on the floor | |
| Director of Nursing | DON B confirmed catheter bags should never be directly on the floor |
Inspection Report
Renewal
Census: 10
Capacity: 20
Deficiencies: 0
Date: May 14, 2024
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for license renewal of the facility.
Findings
The facility was found to be in substantial compliance with all applicable rules and statutes, and the license was recommended for renewal.
Report Facts
Number of staff interviewed and/or observed: 5
Number of residents interviewed and/or observed: 10
Facility capacity: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ian Tschirhart | Licensing Consultant | Author of the inspection report and recommendation |
| Nora Jacobson | Licensee/Licensee Designee | Licensee/Licensee Designee mentioned in the report |
| Sara Heethuis | Administrator | Facility Administrator mentioned in the report |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to comprehensive care planning, medication administration, wound care, and resident positioning in a nursing facility.
Findings
The facility failed to develop person-centered comprehensive care plans for residents requiring oxygen, anti-anxiety medication, and wound care, and failed to ensure professional nursing standards during medication administration and proper use of positioning devices, resulting in potential harm or unmet care needs for several residents.
Deficiencies (4)
Failed to develop a person-centered comprehensive care plan for oxygen use and anti-anxiety medication for Resident #31.
Failed to develop a care plan related to wound care for Resident #38.
Failed to ensure professional standards of nursing practice during medication administration for Resident #249.
Failed to ensure consistent and accurate use of a positioning device for Resident #22, resulting in potential decreased range of motion and related complications.
Report Facts
Residents reviewed for comprehensive care plans: 12
Residents sampled for professional nursing standards: 16
Residents reviewed for positioning: 2
Oxygen liters per minute: 2
Lorazepam dosage: 0.5
BIMS score: 6
Wound care frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN T | Licensed Practical Nurse | Reported on oxygen use for Resident #31 and positioning device use for Resident #22 |
| LPN U | Licensed Practical Nurse | Reported on oxygen order and anti-anxiety medication for Resident #31 and medication administration for Resident #249 |
| RN/NM M | Registered Nurse/Nurse Manager | Reported on care plan expectations for Residents #31 and #38 |
| DON B | Director of Nursing | Reported on care plan expectations and medication administration policies |
| CNA L | Certified Nurse Assistant | Reported on anti-anxiety medication for Resident #31 |
| TM GG | Therapy Manager | Reported on proper application of positioning cushion for Resident #22 |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 25, 2023
Visit Reason
The inspection was conducted to assess compliance with care planning, safety interventions, and facility maintenance standards, including the development and implementation of comprehensive care plans for residents and the cleanliness of air conditioning units.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in missing fall prevention interventions and lack of care plans for peripheral vascular disease treatment. Additionally, the facility failed to maintain air conditioners free from dust and debris in seven of eleven units assessed, increasing the risk of poor air quality.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, including fall prevention and treatment of peripheral vascular disease.
Failed to maintain air conditioners free from accumulation of dust and debris in seven of eleven air conditioners assessed.
Report Facts
Number of air conditioners assessed: 11
Number of air conditioners with dust and debris: 7
Number of residents reviewed for care plans: 2
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN J | Registered Nurse | Reported on care plan interventions and dressing changes for Resident #26 and fall prevention for Resident #38 |
| DON B | Director of Nursing | Reported expectations for staff to review care guides and ensure fall interventions were in place |
| RN Y | Unit Manager Registered Nurse | Confirmed lack of care plan for Resident #26's peripheral vascular disease and venous insufficiency |
| CNA K | Certified Nursing Assistant | Reported on use of care guides for resident interventions |
| CNA E | Certified Nursing Assistant | Reported on staff sign-in and use of care guides for resident care |
| Housekeeping Manager Z | Housekeeping Manager | Reported uncertainty about cleaning schedule for air conditioner units |
| Facilities Manager AA | Facilities Manager | Reported that air conditioner units should have filters cleaned and be serviced twice a year |
| Facilities BB | Facilities Staff | Reported that air conditioner units typically do not get deep cleaned until room deep cleaning after resident moves out |
Inspection Report
Original Licensing
Capacity: 20
Deficiencies: 0
Date: Oct 23, 2015
Visit Reason
The document is an Original Licensing Study Report for Holland Home-Breton Extended Care to determine compliance with licensing statutes and administrative rules for issuance of a temporary license.
Findings
The facility was found to be in substantial compliance with applicable licensing statutes and administrative rules. The newly built facility meets physical, programmatic, and staffing requirements for a 20-bed adult foster care large group home. No rule or statutory violations were found at the time of licensure.
Report Facts
Licensed capacity: 20
Staff-to-resident ratio: 3
Square footage of living space: 1249.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Troy Vugteveen | Licensee Designee | Named as licensee designee and involved in application and inspection process. |
| Sara Heethuis | Administrator | Named as facility administrator and involved in application and inspection process. |
| Arlene B. Smith | Licensing Consultant | Author of the licensing study report and responsible for inspection. |
| Jerry Hendrick | Area Manager | Approved the licensing report. |
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