State inspectors found the facility failed to follow basic infection control practices during a December complaint investigation. Four residents with indwelling catheters, chronic wounds, or feeding tubes lacked the required room signage and personal protective equipment that should have been available for staff providing close contact care.
The violations affected residents who had been living at the facility for months. One patient admitted in February required enhanced barrier precautions due to a Foley catheter, according to his care plan revised in October. When inspectors checked his room on December 26, they found no signage indicating he needed special precautions and no protective equipment for staff to use.
Another resident with an indwelling catheter had a care plan from November requiring enhanced barrier precautions. His room also lacked proper signage and equipment when inspectors arrived.
A third patient needed enhanced precautions for both an indwelling catheter and a chronic wound, according to care plans dating back to January and revised in May. Inspectors found the same pattern: no room signage, no protective equipment available.
The fourth resident required enhanced barrier precautions due to a feeding tube, with care plans from mid-November. Her room similarly lacked required safety measures.
Enhanced barrier precautions are designed to prevent transmission of multidrug-resistant organisms through targeted use of gowns and gloves during high-contact care activities. The facility's own policy, revised in March 2024, requires implementing these precautions to reduce transmission risks.
During interviews on December 30, the Director of Nursing and a registered nurse told inspectors they were both certified infection control practitioners who were new to their roles. They had conducted an audit to identify all residents requiring enhanced barrier precautions.
Both staff members confirmed that the observations made on December 26 revealed enhanced barrier precautions had not been in place as required. When questioned, the registered nurse stated she had not reviewed physician orders or care plans as part of the audit.
The medication incident occurred that same afternoon when Registered Nurse K prepared medications for a resident. While removing a pill from its packaging card, the medication fell onto the top of the medication cart. The nurse scooped up the pill using the medication card and placed it in a plastic cup that already contained other medications for the same resident.
The nurse then took the cup of medications to the resident's room and administered them.
All four residents requiring enhanced barrier precautions had been admitted to the facility with serious medical conditions. Three had neuromuscular dysfunction of the bladder requiring catheter placement. The fourth resident had been admitted with a cutaneous abscess of the abdominal wall and required attention to artificial digestive tract openings.
The inspection was conducted in response to a complaint and resulted in citations for failing to provide and implement an adequate infection prevention and control program. Inspectors determined the violations posed minimal harm or potential for actual harm to residents.
The facility's infection control policy specifically addresses the need for enhanced barrier precautions to prevent transmission of multidrug-resistant organisms. These precautions require targeted use of gowns and gloves during activities that involve close contact with residents who have certain medical conditions or devices.
The lack of proper signage meant staff members could not easily identify which residents required enhanced precautions. The absence of readily available personal protective equipment prevented staff from following required safety protocols during routine care activities.
The medication handling violation occurred during the same inspection period, highlighting broader concerns about adherence to safety protocols at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Holland from 2025-12-30 including all violations, facility responses, and corrective action plans.