Holland Home Breton Rehabilitation & Living Centre

In the surveyor’s words

From the most serious findings on record at Holland Home Breton Rehabilitation & Living Centre, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Apr 30, 2026

  Based on observation, interview, and record review the facility failed to consistently use dignified terms for residents and ensure consistent dignified dining experiences for 10 (Residents #3, 19, 15, 42, 44, 6, 29, 38, 25, & 28) of 45 residents reviewed for dignity resulting in the potential for feelings of shame, embarrassment, and/or decreased meal enjoyment.Findings includeResident #3:Review of Resident #3's admission record, dated 4/30/26, indicated she was an [AGE] year old female with a pertinent diagnosis of dementia (decline in cognitive function).Review of Resident #3's brief interview for mental status, dated 2/26/26, was scored zero which reflected severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF921Jan 25, 2023

  Based on observation and interview the facility failed to maintain air conditioners to be free from the accumulation of dust and debris in seven of eleven air conditioners assessed for cleanliness. This resulted in an increased risk of poor air quality and an increased risk of adding particulate matter to the air in the following rooms. Findings Include: During a tour of the facility, at 1:10 PM on 1/23/23, observation of resident room [ROOM NUMBER] found an air conditioner unit mounted on the far side wall. Observation of the unit found excessive accumulation of black spots and dusty debris. When asked how often these get cleaned, Housekeeping Manager Z stated that facilities would take care of that, and I am not sure of their schedule. […]

• No harm, potential for more than minimal, isolatedF657Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was revised to reflect an increased need for assistance for transfers in 1 resident (Resident #6) of 12 residents reviewed for care plans, resulting in the potential for injury and falls.Findings include:Resident #6Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, repeated falls, unsteadiness on feet, weakness, and difficulty walking. […]

• No harm, potential for more than minimal, isolatedF689Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe transfers were performed and the comprehensive care plan was updated with therapy recommendations in 1 resident (Resident #6) of 3 residents reviewed for accidents/falls, resulting in the potential for injury and falls due to unsafe transfers.Findings include:Resident #6Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, stage 4 pressure ulcer of sacral region (coccyx, tailbone area), repeated falls, unsteadiness on feet, weakness, and difficulty walking. […]

• No harm, potential for more than minimal, isolatedF880Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to effectively implement Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 1 resident (Resident #6) of 12 residents reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population.Findings include:Resident #6Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, stage 4 pressure ulcer of sacral region (coccyx, tailbone area).Review of Resident #6's current Care Plan revealed, .I have an Indwelling Catheter: due to urinary retention and stage 4 pressure ulcer.Review… […]