Medilodge of Zeeland

In the surveyor’s words

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

• Immediate jeopardy, patternF880Aug 23, 2022

  Based on interview and record review, the facility failed to identify a COVID-19 outbreak and properly prevent and/or contain the spread of COVID 19, resulting in a pattern of transmission that sickened 56 residents, contributed to the hospitalization of 1 resident and was highly likely to have been the cause of death for 2 residents. This deficient practice resulted in an immediate jeopardy beginning on [DATE] when the facility failed to recognize and respond appropriately to a COVID-19 outbreak at the facility with the high likelihood of causing serious harm and or death for all residents living at the facility. Findings: Review of a facility policy COVID19 Core Practices updated [DATE] reflected 13. […]

• Immediate jeopardy, isolatedF686Sep 24, 2021

  This citation has two Deficient Practice Statements (DPS). DPS A Based on observation, interview, and record review, the facility failed to properly care for one dependent resident (Resident #9) known to have compromised skin integrity resulting in an Immediate Jeopardy when on 02/19/21, the facility failed to prevent, identify, and treat a pressure sore resulting in the deterioration of the sore to a stage 4 (bone and tendon exposed) wound with [CONDITION(S)] and [CONDITION(S)]. This deficient practice resulted in harm to the resident and inhibited the ability of Resident #9 to reach the highest practicable health and well-being, and has the high likelihood to place all dependent residents at risk for deteriorating skin integrity. […]

• Immediate jeopardy, isolatedF684Apr 9, 2021

  This citation is related to intake #MI00- 9 Based on observation, interview and record review, the facility failed to 1.) carry out a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) notify the physician that the referral was not made, when a registered nurse unilaterally and outside the scope of nursing practice, decided the referral did not need to be made 3.) and immediately report eye concerns to a physician, that was identified by a family member, for 1 of 1 residents (Resident #9) reviewed for quality of care, resulting in an immediate jeopardy when, beginning on 10/05/20, facility staff did not follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, patternF600Dec 5, 2022

  This citation pertains to intakes #: MI 481, MI 243, MI 497, and MI 931 Based on interview and record review, the facility 1.) failed to ensure a comprehensive facility-wide assessment that included an assessment of the staffing needs, resident behaviors (wandering), resident acuity, and staff training and education requirements was complete and accurate, 2.) failed to evaluate the effectiveness of the interventions in place for residents with known behaviors, 3.) failed to identify increased behaviors and revise a care plan and 4.) failed to ensure there was sufficient staffing to supervise residents and prevent resident to resident abuse for 7 residents (Resident #9, #107, #32, #79, #24, #36, #1), resulting in a pattern of systemic neglect leading to resident to resident abuse and the… […]

• Actual harm, patternF867Dec 5, 2022

  Based on interview and record review the facility failed to fully implement its established Quality Assurance Process Improvement (QAPI) plan and adequately and appropriately address known deficiencies resulting in 1.) The inability to sustain substantial compliance with federal regulations, 2.) the potential for unrecognized and incompletely evaluated systems leading to physical and psychosocial harm and diminished quality of life for residents living at the facility. Findings: Review of a facility policy Quality Assessment & Assurance Program revised 9/18/2019 reflected Quality Assurance and Performance Improvement (QAPI) builds upon traditional quality assurance methods by emphasizing the organization and systems. […]