Holland Lake Rehabilitation and Wellness Center

In the surveyor’s words

From the most serious findings on record at Holland Lake Rehabilitation and Wellness Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 8, 2026

  Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service. The facility failed to ensure that the dietary staff performed proper hand hygiene when entering the kitchen area and between tasks. The facility failed to ensure that kitchen equipment and nutrition service areas (nourishment rooms) were maintained in clean and in sanitary conditions. The facility failed to properly label open food items in the kitchen and nutrition areas. […]

• No harm, potential for more than minimal, widespreadF812Aug 31, 2023

  Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. The lids to the bulk storage containers were soiled with food particles. 2. Opened gravy mix and breaded chicken patties were not stored in sealed bags. 3. The vent-a-hood was soiled with grease and the interior surface of the deep fryer unit was soiled with fried food crumbs. 4. Sanitized cooking utensils and pans were stored on hooks suspended in the air from a frame located near the ceiling air duct vents and the sanitized surfaces were not protected from contaminants in the air. 5. […]

• No harm, potential for more than minimal, patternF656Apr 12, 2026

  Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for care plans. 1. The facility failed to ensure the staff implemented the comprehensive care plan goals and interventions for Resident #1. 2. The facility failed to ensure the comprehensive care plan for Resident #2, Resident #3, Resident #4 and Resident #5 described the resident's goals for admission and desired outcomes. 3. […]

• No harm, potential for more than minimal, patternF880Dec 3, 2025

  Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Resident #1 and, Resident #2) of three residents reviewed for infection control in that:-LVN A failed to perform hand hygiene and changed her gloves at the appropriate times while providing urostomy care for Resident #1.-CNA B failed to perform hand hygiene and change his gloves at the appropriate times while providing incontinence care for Resident #2.These deficient practices could place residents at risk for infection due to improper care practices.Findings included: Review of Resident #1's face… […]

• No harm, potential for more than minimal, patternF641Aug 31, 2023

  Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the health status for 4 of 26 residents (Residents #7, #35, #45, and #63) whose MDS assessments were reviewed, in that: 1. Resident #7 had contractures in two fingers of her right hand. Her MDS documented no limitations in ROM. 2. Resident #35 had contractures in the fingers of both hands. His MDS assessments documented no limitations in range of motion in his upper extremities. 3. Resident #45 had contractures in both of her legs. Her MDS assessments documented no limitations in range of motion in her lower extremities. 4. Resident #63 had contractures in two fingers of his left hand. […]