Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Holland during CMS and state inspections, most recent first.
A resident reported that staff removed her personal icy hot without discussing it with her, while also describing loud 3rd shift noise that disrupted sleep and rough, rushed care. Another resident said a CNA was mean and rude, and Resident Council minutes showed repeated concerns about loud 3rd shift staff, door alarms sounding for long periods, and missing laundry/clothing. A Housekeeping Director noted resident ID tags were not staying on clothing through the wash cycle, contributing to missing items.
Medication administration and lab monitoring were not completed as ordered for multiple residents. One resident’s A1C testing was documented as completed without a corresponding lab result, another resident received midodrine without required BP checks and with reused vital signs, and a third resident received isosorbide and metoprolol without current BP or HR assessments despite hold parameters. During observation, an LPN was also seen leaving pills at a resident’s bedside for later self-administration even though the resident had not been approved to self-administer medications.
Mildew-like growth was observed on shower caulk in the 300-hall and 100-hall shower rooms, along with wall covering that was bulging out from the wall in both areas. The HD and SMD acknowledged work orders for the caulking issues.
Advance Directive Not Accurately Reflected in Medical Record: A resident with cerebral infarction and vascular dementia had a legal guardian who signed DNR/no resuscitation documents, but the Order Summary and EMAR banner still showed Full Resuscitation. The DON confirmed the EMAR was inaccurate and stated the Unit Manager was responsible for ensuring advance directive forms were completed and the EMAR matched the resident's or guardian's wishes.
A resident with stroke, vascular dementia, dysphagia, incontinence, and total ADL dependence developed worsening buttocks/coccyx skin breakdown, but the facility did not complete timely wound measurements, weekly skin assessments, provider notification, or care plan updates. The resident was observed without pressure-relieving equipment, and staff and the guardian reported the skin issue had worsened while the resident was in bed and receiving inconsistent pressure injury prevention measures. The DON acknowledged the assessment gaps, and the record showed the Braden Scale and skin documentation did not reflect the resident’s condition.
Inaccurate narcotic documentation was found for 3 residents. One resident was documented as receiving oxycodone after leaving the building for the hospital, and two other residents had morphine sulfate and Norco recorded at the scheduled noon time rather than the actual administration time. For one resident, the remaining morphine volume in the bottle did not match the narcotic record, and the DON stated the discrepancy should have been reported and corrected.
Two residents did not receive medications as ordered: one missed multiple doses of a dementia medication due to unavailability and lack of physician notification, while another received blood pressure medication outside of prescribed parameters on several occasions. The DON could not explain these failures, which did not meet professional standards.
Prescription medications were found unsecured in unlocked treatment and medication carts, and were left unattended at the bedside or on over-bed tables for multiple residents. Facility staff did not consistently follow policy requiring medications to be stored in locked compartments and under direct observation during administration.
Several residents requiring Enhanced Barrier Precautions due to conditions such as indwelling catheters, chronic wounds, and feeding tubes did not have appropriate signage or PPE available in their rooms, as observed by surveyors. Additionally, a nurse was seen administering a medication that had fallen onto the medication cart, placing it back into a cup with other medications before giving it to a resident, in violation of infection control protocols.
A resident with left-sided paralysis and moderate cognitive impairment was found in bed with the call light out of reach. The resident reported this occurred multiple times daily, and a staff member confirmed the call light was not accessible, contrary to facility policy requiring staff to ensure call light accessibility.
The facility did not provide a complete fire alarm sensitivity report, as the documentation only included the range and not the required individual values for all smoke detectors tested. This was confirmed by the Maintenance Director during the survey.
Surveyors observed that smoke barrier doors at a hallway location had an opening greater than 1/8 inch between the door leafs when closed, which does not comply with LSC requirements. This was confirmed by the Maintenance Director and could potentially impact 23 occupants in the affected smoke compartment.
Combustible storage was found obstructing access to electrical panels and the generator transfer switch in a mechanical room, as confirmed by the Maintenance Director. This arrangement did not comply with NFPA 70 requirements for clear access to electrical equipment and could impact occupants and staff if immediate access is needed.
A not full oxygen cylinder was found stored together with full oxygen cylinders in the designated full oxygen storage bin, contrary to NFPA 99 requirements. This improper segregation was observed and confirmed by the Maintenance Director during a facility survey.
The facility failed to maintain an active plan for reducing the risk of Legionella and other pathogens in its plumbing. The Maintenance Director admitted to lapses in testing and using expired test strips, and the facility did not follow its policy requiring regular verification and evaluation of the water management program.
Noise, Missing Laundry, and Rude Care Concerns
Penalty
Summary
The facility failed to maintain comfortable sound levels, keep resident personal property safe from loss, and provide person-centered care for residents involved in Resident Council. The deficiency was identified during interview and record review for three residents and council concerns, and it affected the homelike environment for all 75 residents in the facility. One resident, an alert and oriented female admitted for short-term rehab, reported that a staff member removed her icy hot muscle rub from her bag without discussing it with her and told her it would be locked in the medication cart. She stated she was upset by how the item was taken and described staff as loud in the hallway during 3rd shift, which caused her to keep her door shut and still hear them talking loudly enough to lose sleep. She also reported that some staff were rough with care when turning her and described the care as rushed and thoughtless. Another resident with moderate cognitive impairment stated that a CNA was mean and rude and made her feel bad, and she did not want that aide providing care. A cognitively intact resident reported that 3rd shift was not nice. Resident Council minutes documented ongoing concerns about front door alarms sounding for long periods, missing clothes and laundry, and 3rd shift CNAs being very loud and entering rooms without knocking. The resident council president confirmed these concerns were repeatedly raised, and the Housekeeping Director stated the resident identifier tags on clothing were not staying on through the wash cycle, contributing to missing clothing items.
Medication Administration and Lab Monitoring Not Completed per Orders
Penalty
Summary
The facility failed to ensure medications were administered and laboratory testing was completed in accordance with physician orders for three residents. For one resident with type 2 diabetes, the order summary required a Hemoglobin A1C every three months for diabetic monitoring, and the treatment administration record showed the test as completed, but the electronic medical record contained no laboratory result for the documented date. The record also showed that A1C and TSH were later ordered, and the DON confirmed there had been no A1C or TSH testing on the documented dates and that new orders were placed for the next lab day. For another resident with syncope and heart failure, the order for midodrine required administration three times daily with the instruction to hold for systolic blood pressure greater than 120. The blood pressure record showed several doses were given when the resident’s blood pressure was documented, but on multiple occasions the blood pressure was not assessed immediately before the dose and prior readings were reused instead. The electronic medical record contained no documentation explaining administration outside the ordered parameters, and the DON confirmed the medication errors, including not obtaining vital signs before administration, reusing vital sign assessments, and administering medication outside of parameters. For a third resident with heart failure and hypertension, orders required isosorbide mononitrate and metoprolol succinate each morning with hold parameters based on systolic blood pressure and heart rate. The blood pressure and pulse summaries showed no assessments had been completed for an extended period, yet all doses were still documented as administered during that time. The record contained no documentation explaining the lack of blood pressure and heart rate checks before administration. In addition, during observation another resident was seen with pills left in a cup on the overbed table, and the resident stated staff often left medications for later, including eye drops. The EHR showed that resident had not been assessed or approved to self-administer medications, and the facility policy required licensed nurses to administer medications and observe the resident’s consumption.
Mildew-like Growth and Bulging Wall Covering in Shower Rooms
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the shower areas in the 300-hallway and 100-hallway. On 07/07/2026 at 9:30 AM, surveyors observed black mildew-like growth on the caulk in the 300-hallway shower room, measuring about six to eight inches on either side of the corner at the bottom juncture of the floor and wall. The wall covering directly beneath the shower head was bulging out from the wall, although the wall surface below the covering felt solid. The Housekeeping Director stated that housekeeping had submitted a work order for the caulk to be replaced, and the Senior Maintenance Director stated they were aware of the work order for the caulking in the shower room. Later that morning, at 9:36 AM, surveyors observed black mildew-like growth on the caulk in the 100-hallway shower room, and the wall covering in the shower area was bulging out from the wall. The Senior Maintenance Director confirmed there was a work order for the caulking in the shower room.
Advance Directive Not Accurately Reflected in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's current advance directive was accurately reflected in the medical record for one resident reviewed for advance directives. The resident was an elderly female admitted with diagnoses including cerebral infarction affecting the right dominant side and vascular dementia, and the face sheet identified that she had a legal guardian. Review of the resident's advance directive documents showed that the legal guardian signed forms requesting no resuscitation and authorizing a DNR order if the resident's heart stopped. However, the resident's Order Summary and EMAR banner both reflected Full Resuscitation. During interview, the DON confirmed that the EMAR was inaccurate and stated that the Unit Manager was responsible for ensuring advance directive forms were completed and that the EMAR accurately reflected the resident's or guardian's wishes.
Incomplete skin assessments and failure to follow pressure injury protocol
Penalty
Summary
The facility failed to implement its pressure ulcer prevention and treatment policy and failed to ensure skin integrity assessments were complete and comprehensive for a resident with cerebral infarction, vascular dementia, dysphagia, incontinence, and dependence for all ADLs. The resident was admitted with redness to the buttocks documented on the nursing admission evaluation, but that entry did not include a specific location, measurements, or wound description. The resident’s Braden Scale was completed later and documented a low risk score, but several elements were recorded in a way that did not match the resident’s condition, including sensory perception, mobility, nutrition, and friction/shear risk. During observation, the resident was found sitting in a wheelchair without a pressure-reducing cushion, and there were no pillows, wedges, or other offloading devices in the room for use in bed. The resident’s legal guardian reported that the resident had been left in bed all day on one occasion and that the skin breakdown on the resident’s bottom had worsened. A CNA stated that the resident’s bottom was getting worse and that the resident was now receiving the pink cream used for residents with open areas, whereas the white barrier cream had been used previously. The CNA also reported that hospice staff would be asked for a pressure mattress. The resident’s skin breakdown progressed from a small area to an open area at the coccyx/sacrum, according to CNA observations, but no wound assessment or measurements were completed when the worsening was identified or when the treatment order changed. The record contained no documentation that the provider was notified of the worsening skin breakdown or the need for a change in treatment, and the physician communication book had no related entries. A weekly skin assessment was also not completed as required, and the care plan was not revised after the worsening was identified. The DON acknowledged that the resident’s skin assessment was not completed and stated that measurements should have been obtained on admission and again when the condition worsened. The facility policy required all pressure ulcers/pressure injuries or other skin-related issues to be measured and documented, required notification of the physician and resident representative for new or worsening skin issues, and required the physician to help review and modify the care plan when wounds were not healing or new wounds developed.
Inaccurate Narcotic Administration Documentation
Penalty
Summary
The facility failed to accurately document the administration of narcotics for 3 residents reviewed for narcotic reconciliation. For one resident, staff documented that oxycodone 15 mg was given at 9:30 AM even though the resident had already left the building at 8:40 AM and was transported to the hospital. An RN reviewed the record and stated the time documented was incorrect. For two other residents, the Individual Patient's Narcotic Record showed morphine sulfate 20 mg and Norco 10-325 mg documented as given at noon, but an RN stated the entries reflected the scheduled time rather than the actual administration time. For the resident receiving liquid morphine sulfate, the documented remaining amount was 14.5 mL, while visual inspection of the bottle showed approximately 16.5 mL remaining. The DON stated the discrepancy should have been reported and corrected, and also stated that controlled substances were expected to be documented at the precise time they were administered.
Failure to Provide and Administer Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were available and administered according to physician orders for two residents. One resident with Parkinson's Disease and Dementia had a physician order for Namenda 10 mg twice daily for Dementia. Documentation showed that the medication was not available from the evening of August 12th until the morning of August 22nd, resulting in the resident missing 19 doses. There was no documentation that the physician was notified about the unavailability of the medication during this period. Another resident with hypertensive heart disease, heart failure, chronic kidney disease stage 3, and aortic valve stenosis had a physician order for Hydralazine 25 mg every 12 hours, to be held if blood pressure was less than 140/90. Despite nursing staff documenting blood pressures prior to administration, the medication was given outside the ordered parameters 16 times. During an interview, the Director of Nursing was unable to explain the medication unavailability and the administration of medication outside physician parameters, acknowledging that these actions did not meet professional standards.
Failure to Secure and Supervise Prescription Medications
Penalty
Summary
Surveyors observed that the facility failed to properly secure prescription medications in multiple locations, including two of four treatment carts and one of four medication carts. On several occasions, treatment carts on different halls were found unlocked and contained prescription ointments, bandages, scissors, and other prescription medications. Additionally, a medication cart was observed unlocked and unattended, and prescription medications were left unattended on top of a medication cart. For three residents reviewed, medications were found left at the bedside or on over-bed tables without a nurse present. One resident and their family member confirmed that medications were sometimes left on the bedside table for the resident to take later. Another resident was observed with a cup of pills on the over-bed table while resting, with no nurse present. A third resident and their partner reported that nurses would leave medications at the bedside from time to time, and the partner would ensure the resident took the pills. Facility policy requires all drugs and biologicals to be stored in locked compartments and under direct observation during medication passes, which was not followed in these instances.
Failure to Implement Enhanced Barrier Precautions and Proper Medication Administration
Penalty
Summary
The facility failed to implement and maintain proper infection control practices for residents requiring Enhanced Barrier Precautions (EBP) and during medication administration. Multiple residents with conditions such as neuromuscular dysfunction of the bladder, indwelling catheters, chronic wounds, and feeding tubes were identified as needing EBP according to their care plans. However, observations revealed that there was no signage indicating EBP requirements on their room doors, nor was personal protective equipment (PPE) available for staff to use during close contact care. These lapses were confirmed by the Director of Nursing and a Registered Nurse, both certified Infection Control Practitioners, who acknowledged that EBP had not been implemented as required and that physician orders or care plans had not been reviewed during their audit. Additionally, during medication administration, a registered nurse was observed preparing medications when a pill fell onto the medication cart. The nurse retrieved the pill using the medication card and placed it into a medication cup with other medications before administering them to a resident. This practice did not adhere to proper infection control protocols for medication administration, as the pill was potentially contaminated before being given to the resident.
Call Light Accessibility Not Maintained for Dependent Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident with significant physical and cognitive impairments. The resident, who had left-sided paralysis following a stroke and moderate cognitive impairment, was observed in bed with the touch pad call light out of reach. The resident reported that the call light was out of reach two to three times a day, causing frustration. A staff member confirmed during the observation that the call light was not accessible to the resident. Review of facility policy indicated that staff are educated to ensure resident access to call lights, but this was not followed in this instance.
Incomplete Fire Alarm Sensitivity Testing Documentation
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with NFPA 70 and NFPA 72 standards. During a record review, it was found that the fire alarm sensitivity testing report only included the range of values for smoke detectors tested, rather than providing the required individual values for all smoke detectors within the facility. This incomplete documentation was confirmed during an interview with the Maintenance Director at the time of the survey observation.
Plan Of Correction
The correct bi-annual fire alarm sensitivity report was obtained on 5-6-25. The report was dated 11-27-24 and contains the correct documentation showing sensitivity values for each device. A one-time audit was completed on all fire alarm documentation by the Maintenance Director on 5-7-25 to ensure all inspections contain the correct information. Education was provided to the Maintenance Director on 5-20-25 as to the requirements of the 2-year sensitivity testing report, ensuring that they show the correct values for each device. A monthly audit x3 will be completed by the Maintenance Director or designee to ensure all fire alarm documentation contains the correct information. Audit findings will be presented to the facility QAPI committee and will only be discontinued with substantial compliance and with approval of the facility QAPI. The Administrator is responsible for achieving and sustaining compliance.
Smoke Barrier Doors Not Properly Sealed
Penalty
Summary
During an observation on May 8, 2024, surveyors identified that the smoke barrier doors located at the 100/200 hall did not meet the required standards set by the Life Safety Code (LSC) 19.3.7.8 and 8.5.4. Specifically, when the doors were in the closed position, there was an opening of more than 1/8 of an inch between the door leafs. This noncompliance was confirmed through an interview with the facility Maintenance Director at the time of the observation. The deficiency could potentially affect 23 occupants within the smoke compartment if smoke were to pass through the barrier doors during a fire in the adjoining compartment.
Plan Of Correction
The smoke barrier doors located at 100/200 hall had an astragal installed by the Maintenance Director on 5-21-25 to eliminate the gap between the leafs. A one-time audit was completed by the Maintenance Director on 5-20-25 to ensure all double smoke barrier doors did not have anything over an 1/8 gap between the leafs. Education was provided to the Maintenance Director on 5-20-25 to the requirements of having smoke barrier doors come to a seal to prevent the passage of smoke. A monthly audit x3 will be completed by the Maintenance Director or designee to ensure that there are not any gaps in the double smoke barrier doors. Audit findings will be presented to the facility QAPI committee and will only be discontinued with substantial compliance and with approval of the facility QAPI. The Administrator is responsible for achieving and sustaining compliance.
Combustible Storage Blocking Access to Electrical Panels
Penalty
Summary
Observation on May 8, 2025, revealed that combustible storage was blocking access to the electrical panels and generator transfer switch in the mechanical, networking, and generator transfer switch room. This situation was identified during a walkthrough and confirmed by interview with the facility Maintenance Director at the time of observation. The report notes that this arrangement does not comply with NFPA 70, National Electric Code, which requires clear access to electrical equipment. The deficiency could potentially affect 20 occupants and staff within the smoke compartment if immediate access to the electrical panels is needed during an electrical or fire emergency.
Plan Of Correction
The items in front of the electrical panel in the mechanical/networking/transfer switch room were moved by the Maintenance Director on 5-21-25. A one-time audit was completed by the Maintenance Director on 5-21-25 to ensure all storage room areas and electrical panel locations were free from items which would prevent access to them. Education was provided to the Maintenance Staff on 5-20-25 as to the requirements of having a clear path and space in front of all electrical panels. A weekly audit x4 than monthly x3 will be completed by the Maintenance Director or designee to ensure all areas in front of electrical panels are free from items that would restrict access to them. Audit findings will be presented to the facility QAPI committee and will only be discontinued with substantial compliance and with approval of the facility QAPI. The Administrator is responsible for achieving and sustaining compliance.
Improper Segregation of Oxygen Cylinders in Storage
Penalty
Summary
The facility failed to ensure proper storage of nonflammable gas cylinders in accordance with NFPA 99, 11.6.5. During an observation on the south side of the building exterior, a not full oxygen cylinder was found mixed in with full oxygen cylinders in the designated full oxygen storage bin. This improper segregation of empty and full cylinders was directly observed and confirmed by the facility Maintenance Director at the time of the survey. The deficiency was identified based on the physical arrangement of the oxygen cylinders, where empty and full cylinders were not clearly separated as required. There is no mention of specific residents or staff being directly affected at the time of the observation, nor is there any reference to medical history or conditions of individuals involved. The report focuses solely on the improper storage practice and the failure to comply with established safety standards for gas cylinder management.
Plan Of Correction
The half-empty oxygen cylinder that was located/stored with the full cylinders was removed and put in the correct location on 5-8-2025. A one-time audit was completed on 5-20-25 by the Maintenance Director to ensure all oxygen cylinders were stored in the correct location. Education was provided to the Maintenance Staff on 5-20-25 by the Regional Maintenance Director as to the requirements of proper oxygen storage. A weekly audit x4 and then monthly x3 will be completed by the Maintenance Director or designee to ensure that oxygen storage containers are being stored properly. Audit findings will be presented to the facility QAPI committee and will only be discontinued with substantial compliance and with approval of the facility QAPI. The Administrator is responsible for achieving and sustaining compliance.
Failure to Implement Effective Water Management Program
Penalty
Summary
The facility failed to have an active plan for reducing the risk of Legionella and other opportunistic pathogens in its premise plumbing. During an interview, the Maintenance Director (MD) revealed that he primarily managed the Water Management Plan (WMP) and only convened with a team if issues arose. The MD admitted that the last Legionella test had been conducted over six months ago due to staff turnover and a delay in ordering test bottles. Additionally, the MD used expired free chlorine test strips, which lacked precision, and all logged chlorine test samples were consistently recorded at .25 parts per million (ppm). The facility's policy required a water management team to regularly verify the program's implementation and effectiveness, but this was not being followed as per the observations and interviews. A review of the facility's Water Management Program policy indicated that a water management team, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing, was supposed to be established. The policy also stated that the team should verify the program's implementation and evaluate its effectiveness at least annually using infection control surveillance data, water quality data, and rounding data. However, the facility did not adhere to these guidelines, leading to lapses in the water management program and potential risks to residents' health.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Holland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Inn At Freedom Village | 2.3 mi | ★★★★★ | 3 | 0 |
| Heritage Nursing And Rehabilitation Community | 3 mi | ★★★★★ | 19 | 0 |
| Medilodge Of Zeeland | 3 mi | ★★★★★ | 21 | 0 |
| Resthaven Care Center | 3.6 mi | ★★★★★ | 1 | 0 |
| The Oaks At Jamestown | 10.8 mi | ★★★★★ | 0 | 0 |
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