Federal inspectors found the violations at Medilodge of Holland during a December 30 complaint investigation that revealed systematic failures in infection prevention protocols for residents with catheters, feeding tubes and chronic wounds.
Resident 100 had been living at the facility since February with a Foley catheter that required enhanced barrier precautions under his care plan. When inspectors checked his room on December 26, they found no signage indicating special precautions were needed and no personal protective equipment available for staff providing close contact care.
The same pattern repeated across three other residents. Resident 104, who had an indwelling catheter since his admission, lacked the required room signage and protective equipment when inspectors observed on December 26. His care plan, revised just weeks earlier in December, specifically called for enhanced barrier precautions.
Resident 105 presented an even higher risk profile. His care plan required enhanced precautions for both an indwelling catheter and a chronic wound, yet inspectors found his room unmarked and without protective equipment when they checked at 12:28 PM on December 26.
Resident 106, a woman with a feeding tube and a history of abdominal wall abscess, also had no infection control measures in place despite her care plan requiring enhanced barrier precautions.
The facility's Director of Nursing and a registered nurse, both certified infection control practitioners, admitted during a December 30 interview that they were new to their roles and had conducted an audit to identify residents requiring enhanced barrier precautions. They confirmed that the required precautions had not been in place during the inspectors' observations.
When questioned about the audit process, the registered nurse revealed she had not reviewed physician orders or care plans as part of her assessment.
The medication incident occurred the same day inspectors documented the infection control failures. At 3:36 PM on December 26, Registered Nurse K was preparing medications when a pill popped out of its packaging card and landed on top of the medication cart. The nurse scooped up the pill using the medication card and placed it in a plastic cup containing other medications, then administered all the medications to the resident.
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, defines these precautions as infection control interventions specifically meant to reduce transmission risks.
The violations occurred despite clear documentation in residents' care plans. Resident 100's plan was initiated when he arrived in February and revised as recently as October. Resident 104's plan was updated in early December. Resident 105's plan had been revised in May, and Resident 106's was updated twice in November.
All four residents had medical conditions requiring indwelling devices that create infection risks. Neuromuscular dysfunction of the bladder affected three residents, necessitating catheter use. The fourth resident required a feeding tube due to digestive tract complications and had a history of abdominal infections.
The inspection findings suggest a gap between written policies and actual practice. While the facility maintained detailed care plans specifying enhanced precautions and had certified infection control practitioners on staff, the basic implementation of safety measures failed across multiple residents with high-risk conditions.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, but the failures exposed vulnerable residents to unnecessary infection risks. The combination of missing protective equipment, absent warning signage, and contaminated medication administration created multiple pathways for potential harm to residents already compromised by serious medical conditions.
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.