Federal inspectors found the violations during a December 26 complaint investigation at Medilodge of Holland, documenting failures that put residents with catheters, feeding tubes and chronic wounds at risk of infection transmission.
Resident 100 had lived at the facility since February with a Foley catheter that his care plan said required enhanced barrier precautions. When inspectors checked his room on December 26, they found no signage indicating special protections were needed and no personal protective equipment stationed outside for staff use during close contact care.
The same pattern repeated across three other rooms. Resident 104, admitted earlier in the year with an indwelling catheter, had care plans updated as recently as December 2 requiring enhanced barrier precautions. No signs. No protective equipment.
Resident 105 needed the special precautions for both an indwelling catheter and a chronic wound, according to care plans revised in May. Resident 106 required them due to a feeding tube, with care plans updated just weeks before the inspection in November.
None of the four rooms had the required signage or protective equipment stationed outside.
Enhanced barrier precautions are designed to prevent transmission of multidrug-resistant organisms through targeted use of gowns and gloves during high-contact resident care activities. The facility's own policy, revised in March 2024, requires implementing these protections to reduce transmission risks.
Four days after documenting the missing protections, inspectors interviewed the Director of Nursing and Registered Nurse A on December 30. Both were certified infection control practitioners who said they were new to their roles.
The nursing leaders confirmed they had conducted an audit to identify all residents requiring enhanced barrier precautions. They acknowledged that the December 26 observations revealed enhanced protections "had NOT been in place as required."
When inspectors asked about the audit process, Registered Nurse A admitted she had not reviewed physician orders or care plans as part of her assessment.
The medication incident occurred the same day inspectors documented the missing infection controls. At 3:36 PM on December 26, Registered Nurse K was preparing medications for a resident when she popped a pill out of its packaging card.
The pill landed on top of the medication cart. Instead of discarding the contaminated medication, Nurse K used the medication card to scoop up the fallen pill and placed it in a plastic cup containing other medications for the same resident.
She then carried the cup to the resident's room and administered all the medications, including the one that had fallen onto the cart surface.
The inspection found violations affecting "some" residents at the 120-bed facility. Federal regulations require nursing homes to provide and implement comprehensive infection prevention and control programs to protect residents from healthcare-associated infections.
Medilodge of Holland's failures occurred despite having two certified infection control practitioners on staff and an established policy requiring enhanced barrier precautions for residents with specific medical devices and conditions.
The timing was particularly concerning given that three of the four affected residents had care plans recently revised or initiated, with Resident 106's enhanced barrier precaution requirements established just six weeks before inspectors found no protections in place.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm. The facility now faces potential enforcement action for failing to maintain basic infection control standards that protect some of its most vulnerable residents.
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.