Medilodge of Holland

In the surveyor’s words

From the most serious findings on record at Medilodge of Holland, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Apr 30, 2021

  This citation pertains to intake MI- 8526 Based on interview and record review, the facility failed to ensure staff initiated timely and appropriate Cardiopulmonary Resuscitation (CPR) per standards of care, federal regulation, and their own facility policy and procedures, resulting in an immediate jeopardy when one resident (Resident #7), who was a full code (desired full life saving measures), was found unresponsive and in [CONDITION(S)], and nursing staff did not know how to appropriately respond causing a delay in rescue attempts. Resident #7 subsequently passed and this deficient practice placed all residents, who are designated as a Full Code and who suffer [CONDITION(S)], or are found unresponsive, at risk for serious harm and/or death. […]

• Actual harm, isolatedF689Dec 1, 2022

  This citation pertains to intake M100132402. Based on interview and record review, the facility failed to operationalize policies and procedures, appropriately assess, monitor, notify pertinent parties, implement meaningful care plans, and thoroughly investigate falls, for 1 (Resident #1), resulting in an inappropriate root cause analysis and interventions that lead to subsequent falls causing harm, serious injury and death. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 is an [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses of dementia, cognitive communication deficit, falls and Parkinson's disease. […]

• Actual harm, isolatedF656May 11, 2022

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive and person centered care plan for 3 (Resident #29, Resident #37, and Resident #41), resulting in a lack of activities, assistive positioning devices for contractures not utilized and uncontrolled pain to continue without properly being addressed. Findings include: Resident #29 (R29) Review of the Minimum Data Set (MDS) dated [DATE] revealed R29 is a [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF697May 11, 2022

  Based on observation, interview, and record review, the facility failed to appropriately evaluate, assess and implement measures for constant moderate pain and develop non-pharmacological interventions or utilize resources to minimize pain for 1 (Resident #41) out of a total sample of 20 residents, resulting in unmanaged constant moderate pain that affects daily activities and the quality of life. Findings include: Resident #41 (R41) Review of the Minimum Data Set (MDS) dated [DATE] revealed R41 is an [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880May 8, 2025

  This citation has two deficient practice statements. DPS A Based on observation, interview, and record review, the facility failed to follow standards of practice when caring for peripherally inserted central catheter (PICC) lines for two of two resident's (Resident #230 and Resident #224) reviewed. Findings: Resident #230 (R230) Review of an Admission Record revealed R230 was a [AGE] year old Spanish speaking male, admitted to the facility on [DATE], with pertinent diagnoses of recent surgical removal of the right great toe due to osteomyelitis and the need for IV (intravenous) antibiotics. During an observation on 05/06/25 at 11:42 AM, Registered Nurse (RN) D entered R230's room to hang antibiotics and administer them through the PICC line. The PICC line did not have an end cap on it. […]