Holland, MI

The Inn at Freedom Village

5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

145 Columbia Avenue, Holland, MI

(616) 820-7600

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

39

Certified beds

Average residents

26

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Healthpeak Properties, Inc.

Operator or chain grouping

Approved since

1994-03-22

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

15 facilities

Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars

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

1.54

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

1.09

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

3.20

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

5.83

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

2.63

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

5.16

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

1.07

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.18

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

1.56

CMS adjusted RN staffing hours

Adjusted total hours

5.89

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

32%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,021

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

37.71

Composite VBP score used to determine payment impact.

Payment multiplier

0.9909

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.88

Baseline 19.03% · Performance 21.02% · Measure score 0.88 · Achievement 0.88 · Improvement 0

Healthcare-associated infections

6.67

Baseline 5.55% · Performance 5.84% · Measure score 6.67 · Achievement 6.67 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.89%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 99 · Observed rate 8.08% · Lower 95% interval 7.27%
Discharge to community	55.57%	50.57% 5 pts better	No Different than the National Rate · Eligible stays 107 · Observed rate 57.94% · Lower 95% interval 49.11%
Medicare spending per beneficiary	0.68	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 65 · Denominator 65
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 65
Discharge self-care score	53.7%	53.69% About the same	Numerator 29 · Denominator 54
Discharge mobility score	40.74%	50.94% 10.2 pts worse	Numerator 22 · Denominator 54
Pressure ulcers or injuries, new or worsened	3.08%	2.29% 0.8 pts worse	Numerator 2 · Denominator 65 · Adjusted rate 3.69%
Healthcare-associated infections requiring hospitalization	5.84%	7.12% 1.3 pts better	No Different than the National Rate · Eligible stays 80 · Observed rate 1.25% · Lower 95% interval 2.51%
Staff COVID-19 vaccination coverage	5.17%	8.2% 3 pts worse	Numerator 6 · Denominator 116
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 113
Discharge function score	48.15%	56.45% 8.3 pts worse	Numerator 26 · Denominator 54
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 32 · Denominator 32
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 26 · Denominator 26
Resident COVID-19 vaccinations up to date	32.14%	25.2% 6.9 pts better	Numerator 9 · Denominator 28

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	82.8% 16.9 pts better	81.7% 18 pts better	Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 100.0% · Q3 100.0% · Q4 99.4% · 4Q avg 99.7%
Percentage of short-stay residents who had an outpatient emergency department visit	16.0%	11.5% 4.5 pts worse	12.0% 4 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 14.3% · Expected 10.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	1.3% 0.9 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	79.5% 20.5 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.8%	24.2% 7.4 pts better	23.9% 7.1 pts better	Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 14.3% · Expected 20.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-30 · Fire 2025-01-30

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-02-21 · Fire 2024-02-21

4 health deficiencies

Top issue: Administration (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-02-24 · Fire 2023-02-24

2 health deficiencies

Top issue: Resident Assessment and Care Planning (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-02-18

F · Potential for more than minimal harm 2025-01-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-18

F · Potential for more than minimal harm 2023-02-24

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-04-20

F · Potential for more than minimal harm 2023-02-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-02-24

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 2023-04-20

E · Potential for more than minimal harm 2023-02-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-04-20

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-01-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-04-18

D · Potential for more than minimal harm 2025-01-30

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-03-07

D · Potential for more than minimal harm 2025-01-30

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-03-07

F · Potential for more than minimal harm 2024-02-21

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2024-04-01

F · Potential for more than minimal harm 2024-02-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-02-21

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-02-21

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-04-01

D · Potential for more than minimal harm 2023-08-09

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-09-15

D · Potential for more than minimal harm 2023-08-09

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-09-15

Penalties and ownership