Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Zeeland during CMS and state inspections, most recent first.
A resident with quadriplegia, TBI, and hydronephrosis, who was moderately cognitively impaired and incontinent of stool, reported that staff refused to transfer him from his power chair to bed overnight and did not clean him despite his repeated requests before a scheduled hospital procedure. He arrived at the hospital upset, with multiple buttock pressure injuries, dressings saturated with old and new stool, a strong stool odor, and extensive redness, and hospital staff had to clean him and change three soiled dressings. Facility staff acknowledged responsibility for preparing residents for transport and the resident’s need for a mechanical lift for incontinence care, but the EMR lacked documentation of the off-site appointment, any refusals of bed or care, behavior symptoms, or bowel movements around the time of transfer.
A resident with dementia, communication barriers, and a history of stroke experienced several days of UTI symptoms, behavioral changes, and decreased intake that were identified by hospice, which obtained orders for Levaquin and PRN ondansetron. Facility staff had reported abnormal urine and increased behaviors but did not document timely practitioner or guardian notification, did not track UTI symptoms, and never transcribed or administered the ordered medications, nor documented any rationale or provider notification about the missed treatment. Nursing notes after the hospice visit relied on hospice findings, lacked a comprehensive assessment or updated vitals, and showed no administration of ordered PRN acetaminophen despite documented pain, while PRN Ativan was given without clear behavioral description or pain follow‑up. Later, when the resident refused assessment, only a temperature was recorded, with no further assessment, no documented re‑approach, and no guardian notification, and CNA charting showed no documented care for many hours despite reports the resident was declining. The resident was ultimately found unresponsive and cold with marked lividity and large amounts of dark fluid from his mouth, and the RN did not initiate CPR, while the record showed no licensed nurse assessment or CNA observation for nearly seven hours before he was found.
The facility failed to timely report and document multiple allegations of abuse and resident-to-resident incidents involving several cognitively impaired residents. In one case, a CNA found two residents partially undressed in the same bed and notified a nurse and the NHA, but no incident report, assessment, or physician/guardian notification was documented. In another case, a resident reported that another resident climbed into her bed, pushed against her, and verbally abused her; the NHA was notified by phone but kept the event in a private file and did not report or investigate it as required. Additional allegations included a resident stating she was grabbed by the neck and pushed against a wall, with no corresponding documentation found, and a separate scratching incident that an RN initially documented as resident-to-resident but was later reclassified by management as an injury of unknown origin. These actions and omissions conflicted with the facility’s own abuse/neglect policy requiring prompt reporting of all alleged violations to appropriate authorities within specified timeframes.
The facility failed to timely and thoroughly investigate and document multiple abuse allegations involving several cognitively impaired residents. In one case, a CNA found two residents in a sexually inappropriate situation and reported it, but no incident report, EMR documentation, or physician/guardian notification occurred. In another event, a resident reported that a male resident climbed into her bed, verbally abused her, and had to be forcefully removed; this was kept in a "soft file," not reported to the State Agency, and staff were told not to document it. Additional allegations included a resident reporting that another resident grabbed her by the neck, and a separate incident where one resident was scratched after another walked past; in both situations, required incident documentation, investigation, and accurate classification as resident-to-resident incidents were missing or altered, despite a written abuse policy mandating immediate investigation, interviews, and thorough documentation.
The facility failed to individualize dementia care, revise care plans, and provide adequate supervision for several residents with Alzheimer’s disease and other dementias who exhibited wandering, aggression, and sexually inappropriate behaviors. One resident with alcohol-induced dementia and psychotic disorder repeatedly wandered into others’ rooms, climbed into a female resident’s bed while verbally abusing her, barricaded himself in a room with two female residents, and was found partially undressed in bed with another resident, yet these events were not documented in the EMR and did not result in person-centered care plan changes. Staff reported being told not to document certain resident-to-resident incidents, and key episodes were kept only in risk management or soft files outside the medical record. Other residents with dementia and behavioral disturbances had documented angry outbursts, physical altercations, and alleged neck grabbing, but these behaviors and incidents were not reflected in updated care plans or consistent behavior documentation, leaving staff unaware of the reasons for increased monitoring or 1:1 supervision.
The facility failed to maintain complete and accurate medical records for several residents involved in behavioral and resident-to-resident incidents. Multiple episodes of sexually inappropriate behavior, aggression, and wandering documented by CNAs or reported by residents and families were not reflected in nursing notes or incident reports, and staff providing 1:1 supervision were unaware of the reasons due to missing EMR entries. One resident’s skin tear was minimally documented without follow-up assessment, another resident’s behavior monitoring record showed no behaviors despite reported conflict, and an incident where a resident was found in another resident’s bed with a partially dressed male nearby was not documented in the EMR.
A resident with Alzheimer's and a history of elopement exited through an unsecured window into the courtyard without staff awareness. The CNA noticed the window was open and the screen damaged but only reported the screen issue, not the unsecured window, to maintenance. The lack of thorough communication and prompt repair allowed the resident to leave unsupervised, and staff were only alerted after a neighbor saw the resident outside.
The facility failed to maintain a sanitary and safe environment, as observed in shared bathrooms with dirty exhaust fans, improperly stored oxygen concentrators, and mixed, unlabeled toiletries. Additionally, sewer gas odor and improper storage of supplies under wastewater lines were noted in the pantry and dining areas. A resident reported that his room was not cleaned, with food crumbs and dried substances observed on the floor over several days. These deficiencies indicate a lack of regular cleaning and proper storage practices.
A resident with cognitive intactness and a chronic skin condition was left in a soiled state after a CNA instructed her to wait for assistance, causing emotional distress and physical discomfort. The facility's policy requires immediate attention to residents reporting being soiled, which was not followed, compromising the resident's dignity.
A resident with psoriasis and hemiparesis reported untreated rash and itching under her breast. Dermatology recommended zinc oxide and nystatin, but orders were not placed due to a zinc allergy. The facility failed to follow up for alternative recommendations, and the DON found no documentation of addressing the recommendations.
A facility failed to maintain proper tube feeding precautions for a resident with a feeding tube. During a dressing change, the resident's bed was elevated only ten degrees, contrary to the policy requiring a 30-45 degree elevation to prevent aspiration. The LPN involved was unaware of the policy, and the resident's bed was not adjusted after the procedure.
A resident with a wound vac dressing experienced a breach in infection control during a dressing change. The LPN and Unit Clerk involved did not use proper barriers, failed to sanitize scissors, and did not change gloves or sanitize hands appropriately. The LPN acknowledged the oversight but did not fully recognize the extent of the infection control breach.
A resident with a history of orthopedic issues and recent surgery experienced severe pain that was not adequately managed by the facility. Despite reporting high pain levels, the resident did not receive timely pain medication, leading to a 911 call. The LPN's documentation was inconsistent, and the facility's investigation was incomplete, failing to address the resident's pain management needs effectively.
A resident with multiple diagnoses, including hypertension, did not receive several critical medications upon re-admission to the facility. The LPN responsible for the admission assessment failed to activate necessary medications, and the facility's admission process, which requires verification by a second nurse and a unit manager, was not followed. The Nursing Home Administrator was unaware of the omissions until later informed, highlighting a breakdown in the medication reconciliation process.
A facility failed to ensure nursing staff were competent in reconciling medications during the admission process, leading to a resident not receiving all prescribed medications. The resident, with conditions including seizures and hypertension, was found to be missing critical medications upon discharge from the hospital. Interviews revealed that an LPN missed orders and another nurse did not complete a required second check, with no documentation of training for the latter.
A facility failed to ensure timely physician response to Medication Regimen Review recommendations for a resident with seizures, fibromyalgia, and hypertension. The pharmacist's recommendations to add 'do not crush' instructions and address duplicate therapy were not documented as addressed. Interviews revealed a lack of immediate action on urgent issues, contrary to facility policy.
Failure to Provide Dignified Incontinence Care Before Off-Site Appointment
Penalty
Summary
Facility staff failed to provide dignified care to a quadriplegic resident with a traumatic brain injury and hydronephrosis who was moderately cognitively impaired and dependent on staff and a mechanical lift for incontinence care and transfers to bed. The resident routinely went to the hospital every two weeks for a urinary procedure. On the night before one such scheduled procedure, the resident reported that staff refused to transfer him from his power chair to bed, resulting in him sleeping in his chair. The next morning, prior to transport for the appointment, the resident stated he repeatedly requested to be cleaned after soiling himself while sitting in the hallway, but staff did not provide the requested care before he left for the hospital. Hospital records for that appointment documented that the resident arrived very upset, reported that facility staff had made him sit in his wheelchair all night, and was found with multiple pressure injuries on his buttocks with dressings saturated with old and new stool and extensive redness of the buttocks. A hospital RN confirmed the resident had a strong stool odor, that staff there had to clean old and new stool and change three stool-soiled dressings, and that the smell permeated the unit while the resident expressed embarrassment and frustration. Facility staff interviews indicated that floor staff were responsible for preparing residents for transport and that the resident was known to be incontinent of stool and required a mechanical lift for changing, but there was no documentation in the EMR of the resident leaving for the appointment, of any refusal to go to bed or refusal of care on the dates in question, or of behavior symptoms related to rejection of care. Bowel movement documentation did not reflect a bowel movement around the time of transfer, and there was no record that staff checked or cleaned the resident before transport.
Failure to Recognize Change in Condition, Implement Hospice Orders, and Monitor Resident Prior to Death
Penalty
Summary
The deficiency involves the facility’s failure to promptly identify and act upon a resident’s change in condition, including not implementing ordered treatments and not adequately assessing or monitoring the resident prior to death. The resident was an older male with a history of stroke and on palliative care, with a guardian and advance directives specifying full code status and a desire for all available medical treatments, including transfer to the hospital when necessary. His care plans identified communication barriers (Cambodian language, dementia), risk for impaired communication, and the need to use simple, direct communication and translation support as needed. His urinary care plan directed staff to observe and report signs and symptoms of UTI, and his pain care plan documented a pain threshold of zero, with instructions to administer medications per orders and notify the practitioner if pain was present. Hospice documentation on one evening showed a clear change in condition: strong‑smelling, dark urine for several days, abnormal UA strip with protein, elevated pH, and small amount of blood, low‑grade fever (99.4°F), tachycardia (pulse 102), abdominal tenderness with guarding over the bladder, increased agitation and behaviors, and decreased oral intake with spitting out food. Hospice contacted the physician, who prescribed Levaquin 500 mg daily for seven days for UTI symptoms, and also ordered PRN ondansetron for nausea. The hospice note indicated facility staff had reported the abnormal urine and behaviors had been present for a few days, but review of the EMR showed no documentation that the practitioner or guardian had been notified of these changes before the hospice assessment, and no symptom tracking or UTI monitoring by licensed nurses was provided. The DON acknowledged the EMR did not prompt UTI/symptom charting and that nurses were expected to perform assessments per professional standards. After hospice obtained orders for Levaquin and ondansetron, the facility failed to transcribe these medications into the EMR or administer them at any time before the resident’s death, and there was no documentation explaining the delay or notifying a provider that treatment had not been initiated. The NHA later stated the orders were not found on the fax until two days after they were written. A nurse’s note early the next morning documented that hospice had been in the night before and that the resident had a temperature of 99.4 and pain with palpation, but there was no evidence that the nurse performed an independent physical assessment or obtained updated vital signs at that time. Despite the resident’s documented pain and an order for PRN acetaminophen 650 mg, there was no record that any pain medication was administered following the hospice assessment. Later that day, the resident received PRN Ativan for anxiety, which was documented as effective, but there was no description of the behaviors prompting its use, no linkage to possible pain, and no follow‑up pain assessment. That evening, a nurse note recorded that the resident refused assessments and a temperature of 98.3°F was obtained, but no further assessment findings were documented, and there was no evidence of re‑approach as directed in the behavior care plan or use of observational assessment for non‑verbal pain or decline. There was also no documentation that the guardian was notified of the resident’s change in condition, refusal of assessment, or involved to assist with translation and decision‑making, despite the facility’s Notification of Changes policy and the resident’s inability to make his own decisions. CNA documentation showed no recorded care from 6:00 PM through 6:00 AM, and the NHA stated best practice was rounding every two hours. A CNA on the night shift reported being told at shift change that the resident was declining, with more pain behaviors and refusal to eat, and stated she last checked him around 1:00 AM by quickly checking his brief without disturbing him because of his behavioral history. In the early morning hours, CNAs found the resident unresponsive and cold at approximately 4:20 AM. The RN’s note described no pulse, cold skin, fixed and dilated eyes, mottling, and large amounts of dark, rust‑colored fluid draining from the resident’s mouth and onto the bed and wall when repositioned. The RN documented “blood pooling” and lividity on the resident’s back, and both the RN and CNAs described his back as dark red to deep dark purple. The DON and NHA later reported that CPR was not initiated because RN A determined there were signs of irreversible death, although the State Operations Manual lists specific criteria for obvious clinical signs of irreversible death that differ from those described. Review of the EMR showed no documented licensed nurse assessment or CNA observation for approximately 6 hours and 45 minutes before the resident was found unresponsive. The facility’s Notification of Changes policy required prompt notification of the physician and representative for significant changes in condition and new treatments, but the record lacked evidence that these notifications occurred when the resident’s condition deteriorated and when new orders were obtained.
Failure to Timely Report and Document Multiple Allegations of Abuse and Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to timely report and investigate multiple allegations of abuse and neglect involving several residents with dementia and related psychiatric diagnoses. One incident involved a CNA finding a resident with alcohol-induced dementia and Alzheimer’s disease standing by the head of another resident with Alzheimer’s disease and mood disturbance, with both residents’ pants lowered or partially down while the second resident was lying in the first resident’s bed. The CNA reported the situation to the nurse, who then notified the Nursing Home Administrator (NHA). The NHA acknowledged awareness of this incident but stated she did not report it to authorities because she arrived at the facility within 30 minutes and believed she could immediately rule out concerns. There were no incident reports, statements, assessments, or EMR documentation showing that the incident occurred or that any notifications were made to the physician or guardians. Another unreported incident involved a resident with alcohol-induced dementia and Alzheimer’s disease entering the room of a resident with Alzheimer’s disease and dementia, climbing into bed between the wall and the resident, and pushing his back against her, moving her toward the edge of the bed. The resident expressed concern about her baby doll being suffocated and about being pushed out of bed, and she got up to get the nurse. Staff statements documented that the resident reported being called a derogatory name before the other resident climbed into her bed. The NHA received calls from the facility during the night and was informed of the incident in the early morning hours. The NHA kept a “soft file” on the event, did not conduct an investigation at the time, and did not report the allegation to the State Agency. The NHA later stated she had been looking for willful intent, believed the resident was fine and not upset, and acknowledged that the verbal abuse should have been reported. Additional concerns involved a resident with dementia and behavioral disturbances who reportedly told her guardian and several family members that another resident grabbed her by the neck, held her head against the wall, and caused neck pain on Christmas Eve. An RN, after being questioned by the guardian about this event, could not find any incident report or documentation in the EMR and stated that the resident was in the hallway talking to staff with tears in her eyes and reported that an LPN had applied cream to her neck. The RN reported this to the NHA and was told the incident was already known and had been dealt with, while the NHA later denied awareness of any such incident. In a separate event, the same RN completed a Risk Management document for a scratch on a resident’s forearm after another resident walked past her, initially documenting it as a resident-to-resident incident. Management later changed it to an injury of unknown origin, with the narrative altered to state that the other resident lost balance and accidentally scratched her. The NHA reported not being aware of any contact between these two residents, despite the room change that followed. These events occurred in the context of a written facility policy requiring immediate or timely reporting of all alleged violations of abuse, neglect, or exploitation to the Administrator, state agency, and other required agencies within specified timeframes, which was not followed in these cases.
Failure to Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The facility failed to timely and thoroughly investigate multiple allegations of abuse involving several residents with dementia and related psychiatric diagnoses. One resident with alcohol-induced dementia, Alzheimer's disease, psychotic disorder with delusions, and major depressive disorder was documented by a CNA as sexually inappropriate on a specific date. The CNA later described entering the resident's room and finding another resident with Alzheimer's disease and dementia with mood disturbances lying in his bed with her pants slightly down to her hips, while his pants were lowered with his buttocks exposed. The CNA reported this to a nurse, who then notified the Nursing Home Administrator (NHA). The Unit Manager/RN initially denied knowledge of any sexually inappropriate incidents or the documented behavior task, and there were no incident reports, statements, assessments, EMR documentation, or notifications to the physician or guardians regarding this event. The NHA acknowledged awareness of the incident and stated she did not report it because she arrived within 30 minutes and believed she could rule out concerns, later admitting there was no documentation of the incident or interventions. Another incident involved the same male resident entering the room of a female resident with Alzheimer's disease and dementia in lack of coordination, climbing into bed with her, and refusing to leave. The female resident left the bed to seek help, reporting that the male resident called her derogatory names and climbed into her bed, pushing his back against her and moving her toward the edge of the bed while she worried about her baby doll and being pushed out. Staff statements documented that the male resident verbally abused her with profane language and had to be forcefully removed from the room. The NHA kept this incident in a "soft file," did not report it to the State Agency, and admitted she did not conduct an investigation at the time. A CNA reported being instructed by the nurse, per the NHA, not to document anything about the incident. Later, staff providing 1:1 supervision to the male resident did not know why he required such supervision, and there was no EMR documentation explaining the reason. Additional allegations involved the same male resident and another female resident with dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. An RN reported that this resident's guardian called about a skin tear and relayed that the resident had told multiple family members that the male resident grabbed her by the neck, held her head against the wall, and hurt her neck on Christmas Eve. The RN could not find any incident reports or EMR documentation of this event, although the resident was observed in the hallway tearfully recounting the incident and stating that an LPN had applied cream to her neck. The RN stated she informed the NHA, who said the incident was already known and addressed, but the NHA later reported she was not aware of any incident between these two residents. In a separate event, an RN completed a Risk Management document when a resident with Alzheimer's disease, dementia with psychotic disturbances, and generalized anxiety disorder was found with a scratch on her forearm after another resident with dementia walked past her. The RN initially documented it as a resident-to-resident incident, but management later changed it to an injury of unknown origin, with the narrative altered to state that the other resident lost her balance and accidentally scratched her. The RN was told she could not document it as a resident-to-resident incident because she did not directly witness the scratch, and she did not complete a witness statement. The NHA reported not being aware of any contact between these two residents, despite the room change that followed. These actions and omissions occurred despite a facility policy requiring immediate investigation of suspected abuse, identification and interviewing of all involved persons, and complete and thorough documentation of investigations. The facility’s abuse, neglect, and exploitation policy required immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, preserving evidence, investigating different types of alleged violations, interviewing alleged victims, alleged perpetrators, and witnesses, and providing complete and thorough documentation. Across the described incidents, the facility did not follow these procedures. There were repeated failures to initiate formal investigations, complete incident or risk management reports, document findings and interventions in the EMR, notify physicians and guardians, and accurately classify and record resident-to-resident altercations. In some cases, staff were explicitly instructed not to document incidents, and in others, documentation that initially identified resident-to-resident contact was later changed by management. The NHA acknowledged responsibility for the lack of documentation and agreed that at least one verbal abuse incident should have been reported, but contemporaneous investigative steps and required reporting were not carried out as outlined in the facility’s own policy.
Failure to Individualize Dementia Care, Document Behaviors, and Supervise Residents With Repeated Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to develop individualized, person-centered interventions, to review and revise care plans, and to provide adequate supervision for multiple residents with dementia, resulting in repeated resident-to-resident incidents and undocumented behaviors. Several residents had diagnoses including Alzheimer’s disease, dementia with behavioral or psychotic disturbances, and anxiety or depressive disorders. For one resident with alcohol-induced dementia, Alzheimer’s disease, psychotic disorder with delusions, and major depressive disorder, CNA behavior documentation over a 30‑day period showed wandering, abusive language, threatening behavior, grabbing, pushing, yelling, screaming, and a sexually inappropriate episode. Despite this, there were no corresponding nursing progress notes or care plan changes addressing these behaviors, and staff were unclear why the resident was placed on 15‑minute checks or 1:1 supervision, with no explanation documented in the EMR. The facility also failed to document and care plan multiple serious resident-to-resident incidents involving this same resident and others with dementia. One incident involved a resident with dementia and anxiety found in another resident’s bed, both with pants partially down, which was reported verbally by a CNA and known to the NHA, but not documented in the EMR, and no care plan updates were made for either resident. Another incident involved the same male resident entering a female resident’s room, climbing into her bed, calling her derogatory names, and having to be forcefully removed; staff statements describing this event were kept in a soft file outside the medical record, and no EMR documentation or care plan interventions were created. Staff reported being told by the NHA not to document this incident. In a separate event, the same resident barricaded himself in a room shared by two female residents by placing a chair against the door, requiring multiple staff and police assistance to gain entry; again, there was no EMR documentation of the incident. Additional deficiencies in documentation and care planning occurred with other residents with dementia and behavioral symptoms. One resident with dementia and behavioral disturbances reported that the same male resident grabbed her by the neck and pushed her head against the wall; her guardian relayed this allegation to an RN, who could not find any incident report or EMR documentation, although another LPN acknowledged being informed and texting the NHA about it. Another resident with Alzheimer’s disease, dementia with psychotic disturbances, and generalized anxiety disorder had documented angry outbursts, refusal of medications, and conflicts with roommates, including striking another resident, but her care plan contained no person-centered revisions reflecting these behaviors or a scratching incident that had been initially documented as a resident-to-resident event and later reclassified by management as an injury of unknown origin. Overall, care plans for the residents reviewed, particularly the male resident with alcohol-induced dementia and multiple behavioral issues, lacked meaningful, person-centered interventions or revisions to address wandering, aggression, and resident-to-resident incidents, and key events were either omitted from the EMR or recorded only in non-medical risk management files. The NHA acknowledged awareness of at least some of the incidents, including the sexual incident between two residents and the bed incident involving the male resident and a female resident, and admitted that staff did not document these events in the EMR or reflect physician and guardian notifications. The NHA also stated she was not fully informed of all incidents involving the male resident and another female resident and could not provide documentation of frequent monitoring after those events. Staff interviews revealed confusion about behavior documentation tasks, lack of awareness of documented behaviors, and reports that management directed them not to document certain resident-to-resident incidents as such. The care plan for the male resident with alcohol dependence and alcohol-induced persisting dementia listed wandering and exit-seeking but contained no meaningful, person-centered interventions or revisions to address his documented behaviors and repeated interactions with other residents.
Failure to Maintain Complete and Accurate Medical Records for Behavioral and Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation of resident incidents and behaviors for multiple residents. For one resident, a risk management document dated 12/28/25 referenced an incident in which he was observed in another resident’s room lying on her bed and exposing himself, yet there was no corresponding documentation in the EMR describing the incident, no record of physician or guardian notification, and no documentation of interventions. Another resident’s EMR lacked daily behavior documentation and contained no entries regarding several resident-to-resident incidents on 10/22/25, 12/24/25, and 12/28/25, despite a behavioral health note describing a history of significant behavioral disturbances including yelling, kicking, hitting, pushing, grabbing, wandering, abusive language, threatening behavior, and sexually inappropriate behavior. Certified Nursing Assistant behavior task documentation showed that this same resident was recorded as sexually inappropriate on 12/28/25, with additional behaviors such as wandering, abusive language, threatening behavior, grabbing, pushing, and yelling/screaming documented on 6 days within a 30‑day look‑back period. However, there was no nursing documentation or follow-up in the EMR to address or evaluate these behaviors. Nursing staff, including an LPN and a unit manager RN, reported being unaware of the sexually inappropriate behaviors and incidents, and a CNA and LPN assigned to provide 1:1 supervision to this resident did not know the reason for the supervision and could not find any explanation in the EMR. Another RN reported that when a resident’s guardian asked about an alleged incident in which this behaviorally disturbed resident reportedly grabbed the guardian’s family member by the neck on Christmas Eve, there was no incident report or EMR documentation of the event, even though the resident was later observed in the hallway tearful and talking to staff about it. Additional documentation gaps were identified for other residents. One RN stated she completed a risk management document for a resident-to-resident incident in which one resident ended up with a scratch on her forearm after another resident walked past her, but the event was later reclassified by management as an injury of unknown origin, and the RN did not complete a witness statement. The nursing progress note for the scratched resident only documented that she was observed standing in her doorway with a skin tear to her right forearm, that the area was cleaned and a bandage applied, and that the resident stated it was from a scratch, with no further assessment or follow-up. Behavior monitoring documentation for another resident showed no behaviors recorded during the 30‑day look‑back period, including on the date of the above incident, and nursing progress notes contained no behavior or concern entries for that date. For yet another resident, there was no EMR documentation on 12/28/25 regarding an incident in which she was found sleeping in another resident’s bed while a male resident, inappropriately dressed, was standing in front of her, leaving that event entirely undocumented in the medical record.
Elopement Due to Unsecured Window and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and a psychotic disorder, who had a documented history of elopement and was admitted specifically due to increased elopement risk, was able to exit the facility unsupervised. The resident's baseline care plan indicated a risk for wandering or attempting to leave the facility unattended. On the day of the incident, the resident exited through her bedroom window into the facility's enclosed courtyard without staff awareness, as there was no alarm to notify staff of her exit. Prior to the incident, a Certified Nursing Assistant (CNA) observed that the resident's window was open and the screen was damaged. The CNA reported the hole in the window screen to the Maintenance Assistant but did not communicate that the window itself was unsecured or fully open. The Maintenance Assistant did not assess the reported damage before the incident occurred. As a result, the window remained unsecured, providing an opportunity for the resident to exit the building. The resident was last seen inside the facility around 6:00 pm and was found in the courtyard at 6:15 pm after a neighbor notified staff. A Code Yellow was initiated, and the resident was located and returned inside without injury or distress. The lack of timely and thorough reporting, assessment, and repair of the window and screen, as well as insufficient supervision, directly contributed to the resident's ability to elope from the secured unit.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by several observations and interviews. In rooms 409/411, a shared bathroom was found with a dirty exhaust fan and an oxygen concentrator with a nasal cannula stored under the sink, next to a grossly soiled toilet and a bedside commode pan with a used brief. Certified Nursing Assistant (CNA) B confirmed the inappropriate storage of the oxygen concentrator and the unsanitary condition of the bathroom. Similarly, rooms 404/406 had a shared bathroom with mixed, unlabeled toiletries scattered on the sink and shelf, including opened ointment packets. CNAs B and C acknowledged that the toiletries should have been stored properly and the bathroom should not appear as it did. Additional deficiencies were noted in the Gilead Pantry and dining areas, where sewer gas odor was detected due to an evaporated pee-trap, and supplies were stored under wastewater lines, posing contamination risks. In room 45410, a resident reported that staff never cleaned his room, which was observed to have food crumbs and dried red substances on the floor over several days. Housekeeping Aide K confirmed the presence of these substances, which were easily removed with a wet mop, indicating a lack of regular cleaning. These findings highlight the facility's failure to ensure a clean and safe environment, increasing the potential for contamination and decreasing resident satisfaction.
Failure to Promote Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity of a resident, identified as R21, who was cognitively intact and required assistance with toileting. On the morning of the incident, R21 had a bowel movement and activated the call light for assistance. A CNA responded but informed R21 that she would have to wait to be changed because it had not been two hours since her last change. This left R21 in a soiled state, causing her emotional distress and physical discomfort due to her chronic skin condition. The CNA later discussed the incident with a unit manager and was instructed that residents should be changed immediately if they report being soiled. Interviews with the LPN and the DON confirmed that the facility's policy requires residents to be checked and changed promptly when they report being soiled, contradicting the CNA's initial response. The facility's policy emphasizes treating residents with kindness, dignity, and respect, which was not adhered to in this instance.
Failure to Implement Dermatology Recommendations for Resident's Skin Condition
Penalty
Summary
The facility failed to implement dermatology recommendations in a timely manner for a resident with a skin condition. The resident, who was cognitively intact, reported having a rash, itching, and burning under her right breast that was not being treated by the staff. The resident had been evaluated by a dermatologist, who recommended the application of zinc oxide diaper cream and nystatin topical powder to affected areas. However, upon review of the resident's physician orders, no medicated creams, powders, or lotions were ordered to treat the rash. The dermatology recommendations were reviewed by a nurse practitioner, who noted the resident's allergy to zinc and indicated that the facility would follow up with dermatology for alternative recommendations. Despite this, the nystatin order was not placed, and the facility staff did not contact the dermatology office for alternative recommendations for zinc. The Director of Nursing confirmed that there was no documentation showing that the dermatology recommendations had been addressed prior to the surveyor's conversation with the nurse practitioner.
Failure to Maintain Proper Tube Feeding Precautions
Penalty
Summary
The facility failed to ensure proper tube feeding precautions for a resident receiving enteral nutrition. The resident, who had a history of stroke and dementia, was observed during a dressing change with the head of the bed elevated only ten degrees, contrary to the facility's policy requiring a 30-45 degree elevation during feeding and for at least one hour afterward to prevent gastric reflux and possible aspiration. The enteral feeding pump continued to infuse at the prescribed rate during the procedure, and the head of the bed was not adjusted after the dressing change. An interview with the LPN involved revealed a lack of awareness regarding the policy on bed elevation during tube feeding. The LPN mentioned that the resident had bed controls and could adjust the bed angle independently. The facility's job description for charge nurses includes responsibilities such as administering tube feedings and supporting facility policies, indicating a failure to adhere to established procedures for enteral nutrition management.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control measures during a dressing change for a resident with a wound vac dressing. The resident, who had a history of stroke and dementia, was admitted with a wound vac dressing after being hospitalized for a lump at the hairline of the neck. The dressing change was observed to be conducted by an LPN and a Unit Clerk, where several infection control breaches occurred. The supplies were placed directly on an unprotected over-the-bed table, and unsanitized scissors were used to cut adhesive film for the dressing. Additionally, the LPN did not change gloves or sanitize hands after cleaning the wound, and the scissors were not sanitized before being used again. During an interview, the LPN acknowledged that the Unit Clerk prompted a glove change due to a ripped glove but did not recognize the need to deglove after cleaning the wound. The LPN also admitted that the scissors should have been sanitized and placed in a different location during the procedure. The facility's job description for the charge nurse included understanding and following infection control guidelines, which were not adhered to during this dressing change.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and adequate pain management for a resident, leading to a deficiency in care. The resident, who had a history of orthopedic issues, polyneuropathy, and recent Achilles tendon surgery, reported severe pain levels that were not adequately addressed by the nursing staff. On one occasion, the resident's pain was rated at 10 out of 10, yet there was no timely reassessment or notification to the physician. The resident's pain continued to be severe, and despite being eligible for additional pain medication, it was not administered until after the resident called 911. The incident involved a Licensed Practical Nurse (LPN) who failed to administer pain medication at the scheduled time and did not reassess the resident's pain levels appropriately. The LPN's documentation was inconsistent with the statements provided during the facility's investigation, indicating a lack of awareness of the resident's pain levels and the medication schedule. The resident's family member also expressed concerns about the timeliness of pain management and the overall quality of care, which led to the resident considering hospice care due to the lack of quality of life. The facility's investigation into the incident was incomplete, as key staff members were not interviewed, and there was a lack of documentation regarding the resident's pain tolerance levels. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the deficiencies in pain assessment and management, acknowledging that the resident's pain was not adequately addressed. The resident's care plan did not specify a tolerable pain level, and there were discrepancies in the pain assessments recorded by the staff.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for a resident who was admitted with diagnoses including seizures, fibromyalgia, and hypertension. Upon discharge from the hospital, it was discovered that the resident had not been taking all prescribed medications according to discharge orders. The hospital discharge summary indicated that several medications, including antihypertensives and bowel routine medications, were discontinued by the facility's RN. The LPN responsible for the resident's admission assessment and medication order review failed to activate several critical medications, including Amlodipine, Baclofen, Senna, Miralax, Metoprolol Succinate, and Lisinopril. The Nursing Home Administrator was unaware of the medication omissions until informed by a regional consultant. The facility's admission process, which requires a second nurse and a unit manager to verify admission orders, was not followed. The paper admission checklist was incomplete, and the medical provider also failed to check the admission orders. The facility's policy requires the admission nurse to confirm orders with a physician and ensure the pharmacy has the medication orders, but these steps were not adequately executed, leading to the medication errors.
Failure in Medication Reconciliation During Admission
Penalty
Summary
The facility failed to ensure that nursing staff were competent and adequately trained to reconcile physician's orders and medications during the admission process, which could potentially compromise resident safety and well-being. Resident #101 was admitted to the facility with diagnoses including seizures, fibromyalgia, and hypertension. However, it was discovered that the resident had not been taking all prescribed medications according to discharge orders from a previous hospital stay. A hospital case manager reported that upon preparing the resident for discharge back to the facility, it was noted that the resident was not on antihypertensives or a bowel routine, which were part of her medication list during previous admissions. Interviews with facility staff revealed lapses in the medication reconciliation process. LPN G, who was responsible for the initial review of medication orders upon the resident's return, admitted to missing orders and received written counseling for errors in transcription and placement of orders. Additionally, Prior Nurse E, who was supposed to perform a second check of the admission orders, could not recall if she completed this task and was not documented as having been trained in the admission process and medication reconciliation. The Nursing Home Administrator confirmed the lack of documentation for Prior Nurse E's training and noted that an admission process checklist should have been completed.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews, which noted irregularities or recommendations, were addressed by the physician in a timely manner for one resident. Resident #101, who was admitted with diagnoses including seizures, fibromyalgia, and hypertension, had Medication Regimen Reviews performed by a pharmacist following re-admissions from the hospital. The reviews, dated 6/18/2024 and 6/30/2024, included recommendations to add 'do not crush' instructions for certain medications and to address duplicate therapy. However, there was no documentation that these recommendations were addressed by a medical provider. Interviews revealed that the Nursing Home Administrator could not find evidence that the recommendations had been acted upon. The Regional Consultant reported discussing the reports with a Nurse Practitioner on 7/16/2024. The Nurse Practitioner indicated that she was absent in June and expected urgent issues to be brought to her attention immediately. The facility's policy stated that urgent irregularities should be addressed as soon as possible, but this was not followed, leading to the potential for unnecessary medications and negative side effects.
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What surveyors actually found near you
We read the 424 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Zeeland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Nursing And Rehabilitation Community | 0.6 mi | ★★★★★ | 19 | 0 |
| Medilodge Of Holland | 3 mi | ★★★★★ | 4 | 0 |
| The Inn At Freedom Village | 4.4 mi | ★★★★★ | 3 | 0 |
| Resthaven Care Center | 6.5 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Hudsonville | 8.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.