Medilodge of Zeeland

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to timely meet the needs for seven facility residents (R2, R15, R14, R95, R13, R48, and R6) and failed to respond effectively to the concern of the members of the Resident Council.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a skin care plan for 1 Resident (R13) of 1 resident reviewed for skin care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to formulate and implement a plan of action to monitor, treat, and prevent the worsening of impaired skin for one Resident (R2) of two residents reviewed for impaired skin.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure the safety of 2 two residents (R40) for safe bed mobility and for (R7) to prevent numerous falls, of 12 reviewed for accident hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep an accurate tube feeding record for 1 resident (R40) of one resident reviewed for tube feeding.

Inspectors wroteBased on interview and record review, the facility failed to have a contract and followed the policies and procedures to coordinate hospice services and care for 1 (R 39) of 2 residents reviewed for hospice services.

Inspectors wroteThis citation pertains to intake #2735204Based on interview and record review, the facility failed to provide dignified care to one Resident (R105) of four residents reviewed for quality of care.

Inspectors wroteThis Citation pertains to intake # 2714532 and 2725669Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (Resident #1) out of 3 residents reviewed for quality of care, resulting in continued deterioration and subsequent death.

Inspectors wroteThis citation pertains to intake #2666838Based on interview and record review, the facility failed to timely report allegations of abuse/neglect for 5 (R4, R5, R7, R9, and R10) of 10 residents reviewed.

Inspectors wroteThis citation pertains to intake #2666838Based on interview and record review, the facility failed to timely and thoroughly investigate allegations of abuse for 5 (R4, R5, R7, R9, and R10) of 10 residents reviewed.

Inspectors wroteThis citation pertains to intake #2666838Based on observation, interview and record review, the facility failed to develop individualized interventions, review and revise care plans, and provide adequate supervision for 5 residents (R4, R5, R7, R9, and R10) of 10 residents reviewed for dementia care.

Inspectors wroteThis citation pertains to intake #2666838Based on interview and record review, the facility failed to implement and maintain a system for complete and accurate medical records for 5 (R4, R5, R7, R9, and R10) of 10 residents reviewed for medical records.

Inspectors wroteThis citation pertains to intake #: MI00153297 Based on interview and record review, the facility failed to ensure sufficient supervision and safety measures were in place to prevent an elopement for 1 of 4 residents (Resident #1) reviewed for accidents, safety, and supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting the following areas:

Inspectors wroteBased on interview and record review, the facility failed to promote resident dignity for 1 (R21) of two residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement dermatology recommendations in a timely manner for one resident (R21) of two residents reviewed for skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper tube feeding precautions were implemented and maintained for one resident (R37) of two residents reviewed for enteral feeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were maintained during a dressing change for one resident (R37) of three residents reviewed for infection control.

Inspectors wroteThis citation pertains to intake MI00148411 Based on observation, interview, and record review, the facility failed to assess timely, monitor, treat and adequately control pain for 1 Resident (R1) of 3 Residents reviewed for pain. Review of R1's face sheet dated 2/6/25 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: 11/28/24 encounter for other orthopedic, polyneuropathy (peripheral nerve disorder that affects multiple nerves throughout the body simultaneously), pain in right shoulder, generalized anxiety disorder, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), Pseudobulbar affect (inappropriate involuntary laughing or crying due to nervous system disorder) and mild cognitive impairment. R1 was listed as her own responsible party. [...]

Inspectors wroteThis citation pertains to intake #MI00145408. Based on interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #101) of 3 residents reviewed for medication use, resulting in the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake #MI00145408. Based on interview and record review, the facility failed to ensure nursing staff were competent and adequately trained to reconcile physician's orders and medications during the admission process, resulting in the potential for compromised resident safety and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake #MI00145408. Based on interview and record review, the facility failed to ensure Medication Regimen Reviews, which noted irregularities or recommendations, were addressed by the physician in a timely manner for 1 resident (Resident #101) of 3 residents reviewed for medication use, resulting in the potential for unnecessary medications, negative medication side effects, and for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation interview and record review the facility failed to ensure one medication cart was secure and medications were properly stored in two medication carts and failed to ensure proper labeling and dating of a biological medication in one medication storage room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reduce the risk of contamination in spa and laundry areas and have an ongoing and active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in contamination of surfaces, clean linen, and for water borne pathogens to exist and spread in the facility's plumbing system.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise the Care Plan for one Resident (Resident #3 (R3)) that had been provided a motorized wheelchair.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers for 2 dependent residents (Resident #51 and Resident #101), of 2 residents reviewed for showers.

Inspectors wroteBased on interview and record review the facility failed to ensure quality care was provided to one resident (Resident #16 (R16)) of two residents reviewed resulting in a delayed assessment and subsequent hospital treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services for contractures for 1 (Resident #51) of 1 resident reviewed for contractures.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 resident (Resident #155) from a total sample of 18 residents reviewed, was free from accidents and hazards when a functioning nurse call system was not available in the resident room.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards for tube feedings for 1 (Resident #51) of 2 residents reviewed for tube feedings.

Inspectors wroteThis citation has two Deficient Practice Statements (DPS) DPS #1 This citation pertains to intake M100140945. Based on interview and record review, the facility failed to operationalize policies and procedures and have medications available for 1 (Resident #102) of 1 resident reviewed for new admissions.

Inspectors wroteBased on interview and record review, the facility failed to operationalize policies and procedures and provide informed consent and pertinent labs for 1(Resident #81) of 5 residents reviewed for unnecessary medications/psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to operationalize their policy and procedures and provide vaccines for 2 (Resident #64 and Resident #65) of 5 residents reviewed for vaccines.

Inspectors wroteBased on interview and record review, the facility failed to post the total number of hours scheduled and actual number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for 6 of 6 days reviewed.