Cycle 1
Health 2025-03-26 · Fire 2025-03-26
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Grand Rapids, MI
Holland Home Breton Rehabilitation & Living Centre
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2589 44th Street SE, Grand Rapids, MI
(616) 643-2500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-09-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.33
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.30
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.92
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
6.29
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
209
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
77.88
Composite VBP score used to determine payment impact.
Payment multiplier
1.0253
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
5.43
Performance 6.21% · Measure score 5.43 · Achievement 5.43 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.93
Baseline 46.88% · Performance 31.25% · Measure score 7.93 · Achievement 7.93 · Improvement 6.59
Adjusted total nurse staffing
10
Baseline 5.35 hours · Performance 5.98 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 7.02% · Lower 95% interval 6.61% |
| Discharge to community | 46.53% |
50.57%
4 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 44.68% · Lower 95% interval 36.38% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 85% |
95.27%
10.3 pts worse
|
Numerator 17 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 1 · Denominator 20 · Adjusted rate 5.26% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 2.93% |
| Staff COVID-19 vaccination coverage | 4.62% |
8.2%
3.6 pts worse
|
Numerator 8 · Denominator 173 |
| Staff flu vaccination coverage | 41.48% |
42%
0.5 pts worse
|
Numerator 73 · Denominator 176 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.0%
2.4 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.1%
0.3 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.6% · Q3 2.7% · Q4 3.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.5%
0.7 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 9.1% · Q4 3.2% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
19.6%
4 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.6% · Q3 12.1% · Q4 16.1% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
16.5%
6.9 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.7% · Q3 14.3% · Q4 10.7% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.6% |
13.9%
1.7 pts worse
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
11.7%
2.9 pts worse
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 15.2% · Q3 15.6% · Q4 20.0% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
20.4%
5.6 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 11.9% · Q3 28.5% · Q4 50.9% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.6%
0.2 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 10.2% · Q3 3.1% · Q4 3.4% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
82.8%
7.8 pts better
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 92.6% · Q3 90.7% · Q4 87.9% · 4Q avg 90.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.3% |
79.5%
12.2 pts worse
|
79.7%
12.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-01-25 · Fire 2023-01-25
2 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-23
E · Potential for more than minimal harm
2024-03-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-23
D · Potential for more than minimal harm
2024-03-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-14
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-19
E · Potential for more than minimal harm
2023-01-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-21
Penalties and ownership
What sits behind the stars
Ownership
Christian Living Services
5% Or Greater Direct Ownership Interest · Organization
Deckinga, Brandyn
Operational/Managerial Control · Individual
Demaagd, Scott
Corporate Director · Individual
Duemler, Ronald
Operational/Managerial Control · Individual
Heethuis, Sara
Operational/Managerial Control · Individual
Heethuis, Sara
Corporate Director · Individual
Hidalgo, Carlos
Corporate Director · Individual
Himmelein, Doug
Operational/Managerial Control · Individual
Johnson, Mark
Corporate Director · Individual
Johnson, Mark
Corporate Officer · Individual
Kinder, Adam
Operational/Managerial Control · Individual
Kinder, Adam
Corporate Officer · Individual
Knibbe, David
Corporate Director · Individual
Malburg, Gary
Corporate Director · Individual
Malburg, Gary
Corporate Officer · Individual
Matro, Philip
Operational/Managerial Control · Individual
Nagelkerk, Jean
Corporate Director · Individual
Sanchez, Nelson
Corporate Director · Individual
Sanchez, Nelson
Corporate Officer · Individual
Schaab, Scott
Operational/Managerial Control · Individual
Segovia, Gilbert
Corporate Director · Individual
Smith, David
Corporate Director · Individual
Tatreau, Anne
Operational/Managerial Control · Individual
Thole, Nick
Corporate Director · Individual
Ursul, Mary
Corporate Director · Individual
Vanderkooi, Marie
Corporate Director · Individual
Vogel-Vanderson, Susan
Corporate Director · Individual
Vugteveen, Troy
Operational/Managerial Control · Individual
Vugteveen, Troy
Corporate Director · Individual
Vugteveen, Troy
Corporate Officer · Individual
Watson, Sam
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Corewell Health Rehabilitation & Nursing Center -
Grand Rapids, MI
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Optalis Health and Rehabilitation of Grand Rapids
Grand Rapids, MI
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $134,605 in total fines with 44 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Optalis Health & Rehabilitation at Kent-Crossing
Grand Rapids, MI
1-star overall rating with 1-star inspections with 22 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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