Heartwood Lodge Trinity Health
Open-data reference.
Heartwood Lodge Trinity Health is a non profit - corporation facility in Spring Lake, MI with 84 certified beds and a 1-star overall CMS rating. The facility has 37 deficiency records on file.
18525 Woodland Ridge Drive, Spring Lake, MI 49456
Phone: 6168420770
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 235373
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 84
- Residents
- 71
- In Hospital
- No
- County
- Ottawa
- Last Inspection
- Jun 13, 2025
Staffing Data
- RN Hours
- 0.38 (nat'l avg: 0.68)
- LPN Hours
- 1.12
- CNA Hours
- 2.81
- Total Nursing Hours
- 4.30 (nat'l avg: 3.89)
- PT Hours
- 0.05
- Nursing Turnover
- 49.6%
- RN Turnover
- 75.0%
What the CMS Record Reveals About Heartwood Lodge Trinity Health
Heartwood Lodge Trinity Health operates 84 certified beds in Spring Lake, MI with approximately 71 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (3★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 37 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 4.30 total nursing hours per resident day (national average 3.89), with RN coverage at 0.38 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Heartwood Lodge Trinity Health falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 49.6%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (37 most recent)
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Sep 12, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Jul 10, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 10, 2025
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category: Administration Deficiencies
Corrected: Jul 10, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Category: Administration Deficiencies
Corrected: Jul 10, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 30, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Jul 10, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jul 10, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 10, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 10, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 30, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 10, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 10, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 10, 2025
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 10, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 10, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Jul 30, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 10, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Jul 10, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Jul 10, 2025
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category: Resident Rights Deficiencies
Corrected: Jul 10, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Jul 10, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 10, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 30, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 1, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 5, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 5, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 5, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Aug 5, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Aug 5, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 5, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Aug 11, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 11, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 12.6% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.2% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 92.3% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 94.8% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 20.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 12.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 77.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 85.9% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 10.4% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 15.7% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 25.8% | Yes |
Penalty History
| Date | Type | Amount |
|---|---|---|
| Apr 23, 2025 | Payment Denial | - |
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Frequently Asked Questions
What is the overall CMS rating for Heartwood Lodge Trinity Health?
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Does Heartwood Lodge Trinity Health have any deficiencies on record?
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When was Heartwood Lodge Trinity Health last inspected?
What quality measures are tracked for Heartwood Lodge Trinity Health?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.