Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 The Laurels Of Hudsonville during CMS and state inspections, most recent first.
A resident with CHF, bacteremia/sepsis, AKI, cardiomyopathy, and diabetes deteriorated while staff documented SOB, low SpO2, abnormal labs, weight gain, edema, and inconsistent oxygen/CPAP use, yet the chart lacked timely physician acknowledgment and the resident’s DNR advance directive was not reflected in the EMR, with CPR started before the code status was reviewed. The facility also gave antibiotics and midodrine in ways not aligned with the hospital transfer instructions, and another resident received clonazepam later than scheduled and was sent to the hospital after an extra dose and altered mental status.
Missing Competency Skills Checks for Nursing Staff: Review of 3 nurses and 3 CNAs showed that none had completed skills checks upon hire or annual competency checks in their files. The HR Manager confirmed that current staff also had no verified competencies on file and stated the previous DON had not completed any competencies.
A resident with CHF, cardiomyopathy, diabetes, and cognitive communication deficit had an advance directive requesting no CPR, but the EMR listed the resident as Full Code. When the resident was found unresponsive with no HR or respirations, staff initiated chest compressions, transferred the resident to the floor, and continued CPR until the DNR paperwork was located and CPR was stopped.
A resident with cognitive impairment, diabetes, pressure ulcers, and an above-knee amputation was discharged without a safe discharge plan. Facility staff did not document review of the resident’s capacity and DPOA paperwork with the physician, did not honor the existing medical DPOA, and sent the resident home with insulin and other medications despite confirmed ADL dependence and transfer assistance needs. The resident was left at home without written discharge instructions and later required hospital care after failing the discharge.
A facility failed to develop and implement complete person-centered care plans for two residents. One resident had multiple wounds, an amputation, diabetes, and moderate cognitive impairment, yet staff did not honor hospital capacity documentation or the DPOA, and the care plan still listed extensive assistance needs when he discharged home independently without documentation of independence or a home eval. The other resident’s care plan did not adequately address discharge planning, pain specifics, or multiple comorbidities including CHF, CAD, HTN, sleep apnea, anemia, and advance directives.
A resident admitted with enterococcal infection and sepsis had antibiotic orders that did not match the hospital transfer instructions, which called for IV ampicillin. The MAR instead showed oral amoxicillin and later IV daptomycin, with no cultures available to confirm sensitivity or appropriateness. Lab results showed elevated neutrophils, but there was no documentation that the practitioner acknowledged the abnormal value. Nursing notes also documented cloudy, thick urine and a later urine culture with Citrobacter and Candida tropicalis, while the DON stated cultures and antibiotic stewardship documentation could not be found.
A resident called 911 and reported being abused and held against her will by staff. Two CNAs became aware of the resident's allegations but did not notify the facility's Abuse Coordinator or Administrator, and the incident was not reported to the State Agency as required by facility policy.
Staff failed to maintain the required head-of-bed elevation during tube feeding and did not consistently label tube feeding solutions and hydration bags with the date and time of initiation, as required by facility policy. These deficiencies affected multiple residents with complex medical needs who were dependent on enteral nutrition.
A resident with a history of stroke and total dependence on staff was administered two muscle relaxants, Methocarbamol and Baclofen, at the same time due to a failure to discontinue one medication when the other was started. This medication error was not recognized by nursing staff, resulting in the resident becoming somnolent and unarousable and requiring hospital evaluation.
A resident at a facility developed multiple unstageable pressure wounds on their feet, which were not promptly or adequately addressed, leading to serious infection and delayed healing. Despite being at risk for pressure ulcers, the resident's feet were not properly elevated, and the facility's care plan interventions were insufficient. The wounds were not evaluated by a wound care consultant until three weeks after the consultation was requested, and there was a lack of appropriate treatment orders. Additionally, a wound culture was not ordered when the resident showed signs of sepsis, contributing to the worsening of the resident's condition.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with unstageable wounds, as required by their infection control policy. Observations revealed no signage or PPE available, and staff did not use the necessary PPE during high-contact care. The resident's care plan and order recap report did not reflect the need for EBP, and an RN was unaware of the requirement, indicating a gap in staff training and policy implementation.
A facility failed to administer daily medications to a resident on dialysis days, resulting in missed doses of critical medications. The resident, with conditions such as hemiplegia and end-stage renal disease, did not receive their morning medications on dialysis days, and the facility lacked orders for dialysis in the resident's records. Interviews revealed that the nursing leadership was unaware of the missed doses and did not notify a physician.
A resident with a PEG/J tube experienced repeated clogging incidents due to inadequate care and maintenance by the facility. Despite hospital instructions to flush the tube with warm water and use liquid medications, the facility failed to implement these measures, resulting in multiple emergency department visits. Interviews revealed a lack of staff training and communication regarding PEG/J tube care.
A resident with complex medical needs experienced repeated clogged PEG/PEGJ tubes due to inadequate nursing competency and training, resulting in multiple hospital visits. The facility failed to ensure nursing staff had current skills and assessments for PEG/PEGJ tube care, leading to improper management and tube damage.
The facility failed to maintain an effective infection prevention and control program, lacking a current infection tracking report and proper hand hygiene practices. The ADON struggled with the new infection control system, and there was no tracking of employee illnesses. An LPN was observed not changing gloves or performing hand hygiene during a resident's wound assessment, potentially leading to cross-contamination.
A facility failed to appoint a legal surrogate for a resident deemed incapable of making informed medical decisions. Despite the resident's daughter frequently visiting and being expected to provide legal guardian paperwork, it had not been submitted. The Director of Social Services expressed concern and noted the need for a court-appointed guardian if documentation is not provided.
A facility failed to ensure that the responsible party for a cognitively impaired resident was informed of the risks and benefits of an antipsychotic medication and had consented to its administration. Despite a doctor's order for Lurasidone, there was no documentation that the Power of Attorney (POA) had been informed or had consented. The Director of Nursing and Nursing Home Administrator were unable to provide the necessary documentation during the survey.
A resident with dementia and diabetes, who was cognitively intact, had an active leg infection that was not updated in their care plan, leading to potential inconsistent care. The unit manager responsible for updates had left, and the DON and MDS nurse were believed to be responsible. The infection was not discussed in clinical meetings, and the PA only informed a floor nurse about the antibiotics, failing to notify the interdisciplinary team.
A facility failed to assess and monitor a resident with chronic kidney disease, leading to hospitalization due to a suspected UTI. The resident's catheter was not changed as ordered, increasing infection risk. Additionally, another resident's skin conditions were not identified or treated, despite being cognitively intact and reporting issues. The facility's policies on skin management were not followed, resulting in potential deterioration of the resident's well-being.
A resident with dementia, morbid obesity, and dysphagia experienced significant weight loss, which was not adequately monitored or addressed by the facility. Despite the addition of a nutritional supplement, the care plan lacked specific interventions for weight loss, and there was no evidence of consistent monitoring or medical referrals. The DON and NHA considered the weight loss desirable but failed to provide supporting documentation.
A facility failed to verify feeding tube placement before administering medication to a resident with a PEG tube, contrary to its policy. The LPN did not aspirate stomach contents as required, relying instead on listening for air bubbles. Interviews revealed a lack of adherence to the policy and unclear procedures, risking complications like aspiration pneumonia.
A resident experienced significant weight loss after admission, but the facility failed to identify and report this to the Medical Provider. Despite the resident's weight history showing a substantial decrease, progress notes inaccurately stated no weight loss. The facility's documentation lacked evidence of timely evaluation or intervention by the Medical Provider, and there was no consistent monitoring or referral for the resident's weight loss.
The facility failed to address pharmacy recommendations for two residents, leading to deficiencies in medication management. One resident with dementia and bipolar disorder had unreviewed pharmacy recommendations for lab values and an AIMS assessment. Another resident with a history of stroke had unreviewed recommendations for anticoagulant dosage reduction and nutritional supplement evaluation. These recommendations were not reviewed by the physician until prompted by the surveyor.
A facility failed to maintain complete and accurate medical records for a resident, resulting in potential miscommunication about the resident's healthcare status. An antibiotic order was noted in the EHR for treating the resident's lower legs, but there was no further documentation from nursing staff or medical providers. The ADON and PA acknowledged the lack of documentation, with the PA stating she had not finished documenting the treatment for chronic lower leg venous stasis dermatitis.
Failure to address abnormal labs, honor code status, and provide ordered care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for multiple residents, including R13 and R1. For R13, the record showed an advance directive signed by the resident and physician requesting no CPR, yet the EMR listed the resident as Full Code. During the night before the resident’s death, CNA J reported that R13 had trouble breathing, had low oxygen levels, and that RN K became upset when asked to assess the resident. CNA J stated RN K told her he would not send anyone out on his watch, and R13 was later found unresponsive before a code blue was initiated. A later note documented that code status was DNR and CPR was halted after the advance directive was reviewed. The facility also failed to address abnormal laboratory values and to recognize and respond to changes in R13’s condition. The record showed abnormal labs including low hemoglobin and hematocrit, elevated BNP, elevated potassium, and abnormal infection-related values, but there was no documentation that the practitioner acknowledged or addressed them. Nursing notes documented shortness of breath, oxygen saturation of 81% on room air, and later worsening lab values including hemoglobin 5.5, hematocrit 18.1%, potassium 5.8, BNP 1477.2, and CO2 17.0, yet the record did not show timely physician acknowledgment of those results. The resident also had diagnoses including CHF, bacteremia due to Enterococcus, AKI, cardiomyopathy, diabetes, hypertension, and atrial fibrillation, and the chart reflected IV antibiotics ordered at hospital discharge, but the facility documentation showed oral amoxicillin and later daptomycin without cultures provided to show sensitivity. Additional failures for R13 included lack of appropriate monitoring and physician oversight related to CHF, weights, edema, oxygen therapy, pain, and midodrine. The record showed weight changes, including a 4.5-pound gain in 24 hours, but there was no documented baseline or goal weight and no documentation that practitioners were aware of the gain. Notes also showed edema, shortness of breath, CPAP use without an order, and delayed or absent documentation for ordered nebulizer treatments. Midodrine was ordered as scheduled every 6 hours despite a prior PRN hospital instruction, and the MAR showed it was given multiple times even when systolic blood pressure was above 90. For R1, the facility failed to provide medications at the ordered times; the police report and hospital record showed she received clonazepam later than scheduled, then was sent to the hospital for altered mental status after an extra dose was given.
Missing Competency Skills Checks for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff and nursing aides had appropriate competency training upon hire and annually. Review of 6 employee files, including 3 nurses and 3 CNAs, showed that none of the files contained completed skills checks upon hire or annual skills checks. Only one of the nurses reviewed was still employed at the time of the review. During an interview, the HR Manager verified that the 6 files did not contain completed competency skills checks and stated that the previous DON had not completed any competencies for current staff. The HR Manager also stated that the facility was trying to develop a system to ensure completion, and that the new ADON would be working on this.
Failure to Honor DNR Status During Emergency Response
Penalty
Summary
The facility failed to honor a resident's DNR wishes when the resident was found unresponsive and CPR was initiated. The resident had diagnoses including congestive heart failure, cognitive communication deficit, cardiomyopathy, enterococcus infection, and diabetes. An Advance Directive signed by the resident and physician stated no CPR, but the EMR order summary listed the resident as Full Code. When the resident was observed not breathing and without a heart rate or respirations, staff called a code blue, started chest compressions, transferred the resident to the floor for CPR, and applied AED pads before the DNR status was recognized. A late-entry nursing note stated that CPR was halted only after code status documentation was reviewed and a copy of the advance directive was handed to MDS. In interview, the former Unit Manager/RN stated the EMR displayed the resident as Full Code and that the discrepancy was not identified until after EMS had taken over CPR. The Social Worker stated that code status documentation was updated weekly and that nursing staff were responsible for changing the EMR, while medical records scanned the advance directives into the chart after updates were made.
Failure to Formulate Safe Discharge Plan
Penalty
Summary
The facility failed to formulate a safe discharge plan for a resident who was admitted with peripheral vascular disease, unstageable pressure ulcers of the left ankle and heel, frontotemporal neurocognitive disorder, diabetes mellitus type 2 with neuropathy, and an above-knee amputation of the right leg. The resident’s BIMS score indicated moderate cognitive impairment, and the admission conference documented that he was a long-term care patient, was taking psychoactive medications, and that there were concerns about his capacity to make decisions. The record also showed hospital discharge paperwork naming a family member as his medical DPOA and included written statements from physicians indicating that he did not possess the capacity to fully understand new clinical information or direct responsible medical decision-making on his own behalf. Despite this documentation, facility staff did not locate any record showing that the resident’s safety concerns or the hospital capacity documentation were reviewed with the facility physician. The social worker stated the facility did not honor the hospital documentation because it was signed by an RN and a social worker and said it took two physicians to determine incapacity, while not addressing the physician statements in the record that supported lack of capacity and activation of the medical DPOA. The social worker also stated the physician did not revoke the DPOA because the hospital papers were believed not to be legally binding. The nursing home administrator later confirmed there was no documentation revoking the DPOA or showing review of the resident’s safety concerns with the physician. The resident was discharged home with medications, including insulin in vials and pens, although staff confirmed he was not independent with all ADLs and was noncompliant with using his call light for assistance with transfers. The social worker and LPN confirmed the resident signed himself out and was transported home by the facility driver. The DPOA reported that the facility did not honor the existing DPOA paperwork, that no written discharge instructions were found, and that the resident was left at the bottom of the steps to his home, where family had to physically assist him. The resident later failed the home discharge and was taken to the hospital by the DPOA.
Incomplete person-centered care planning and discharge planning
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed the needs of two residents. For one resident, the record showed multiple diagnoses including peripheral vascular disease, unstageable pressure ulcers of the left ankle and heel, frontotemporal neurocognitive disorder, diabetes with neuropathy, and a right above-knee amputation. The resident had a BIMS score of 10/15 indicating moderate cognitive impairment, and hospital discharge paperwork identified a DPOA and documented that the resident lacked capacity to fully understand clinical information and to direct medical decision-making. Despite this, facility staff continued to treat the resident as his own decision maker, and the social worker stated the hospital documentation was not honored because it was signed by an RN and SW, while also not finding documentation that the physician reviewed the capacity concerns. The same resident’s care plan continued to list extensive assistance needs, including supervision or partial assistance with bathing, dressing, hygiene, transfers, toileting, and mobility, with a slide-board transfer plan and a home safety visit prior to discharge. Those interventions remained current when the resident discharged home independently, but there was no documentation that he was independent with those tasks or that a home evaluation occurred before discharge. Staff also confirmed the resident was not independent with all ADLs and was noncompliant with using his call light for assistance. The DPOA reported the facility did not honor the existing DPOA paperwork and that the resident was left at home in his wheelchair at the bottom of the steps, after which family had to physically assist him and later took him to the hospital because he could not independently care for himself or manage medications. For the second resident, the care plan did not adequately address discharge planning or the resident’s medical conditions. The resident was admitted for short-term rehab after hospitalization for UTI and had diagnoses including CHF, cardiomyopathy, cognitive communication deficit, enterococcus infection, diabetes, CAD, HTN, sleep apnea, and anemia. The care plan included only a general discharge-related intervention to provide contact numbers for community referrals and a pain need that directed staff to administer medications and observe for side effects, but it did not address acute versus chronic pain or pain location. The record also lacked a care plan addressing the resident’s comorbidities, including CHF, bacteremia/sepsis, sleep apnea, anemia, or advance directives.
Failure to Verify Appropriate Antibiotic Therapy
Penalty
Summary
The facility failed to ensure the appropriate antibiotic was implemented for one resident admitted with congestive heart failure, cognitive communication deficit, cardiomyopathy, enterococcus infection, and diabetes. The hospital transfer document stated the resident was to continue IV ampicillin 2 g every 12 hours for 2 weeks from 6/8/25 through 6/22/25 for Enterococcal bacteremia, but the MAR showed amoxicillin 500 mg by mouth twice daily for bacteremia for 9 days instead. The record also showed daptomycin-sodium chloride IV every 48 hours for Enterococcus infections for 10 days, given on 6/18/25, 6/20/25, and 6/22/25, with no cultures provided to show sensitivity or appropriateness of the antibiotic choice. Laboratory testing collected on 6/16/25 showed neutrophils at 82.1%, and there was no documentation that the practitioner acknowledged the abnormal lab value. A practitioner progress note on 6/18/25 documented that daptomycin was started for ongoing sepsis and stated the resident had been hospitalized for sepsis caused by a ureteral stone. A skilled care note on 6/21/25 documented continued IV antibiotics for bacteremia/UTI. A nursing progress note on 6/23/25 documented that a urine specimen was sent to the hospital lab because the urine was thick, murky, and tan, but there was no documentation that the physician was notified before the specimen was sent. The urine culture later showed Citrobacter and Candida tropicalis. During interview, the DON stated cultures could not be found to verify that the resident received the appropriate antibiotics and could not find documentation showing antibiotic stewardship for the resident.
Failure to Report Resident's Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency for one resident. The resident, a female recently admitted to the facility, used her phone to call 911 and reported to the dispatcher that she was being held against her will, had been assaulted by staff, was not allowed to make phone calls, and implied that she had been sexually assaulted by staff. A CNA discovered the resident on the phone with 911, spoke to the dispatcher, and explained that the resident was confused and the call was a mistake. Despite being aware of the resident's allegations, the CNA did not notify the facility's Abuse Coordinator. Further interviews revealed that another CNA was also aware of the 911 call and the resident's abuse allegations but did not report the incident to the Administrator/Abuse Coordinator, assuming that the nurse would handle it. The Administrator/Abuse Coordinator was not aware of the incident or the police visit until interviewed by surveyors. The facility's policy requires that all allegations of abuse be immediately reported to the Administrator and appropriate state agencies, but this protocol was not followed in this case.
Failure to Follow Tube Feeding Protocols and Documentation Requirements
Penalty
Summary
The facility failed to follow professional guidelines and its own policies regarding the care of residents receiving tube feedings. For three residents reviewed, staff did not maintain the required elevation of the head of the bed during tube feeding, as care plans and facility policy specified a semi-Fowler's position (30-45 degrees) during and after feeding to prevent aspiration. Observations showed that the head of the bed was consistently below the required elevation, with one resident's bed at 10-20 degrees and another at 12-22 degrees during active tube feeding. Additionally, a CNA interviewed was unaware of the correct bed elevation required for tube feeding care. Further deficiencies were noted in the labeling and documentation of tube feeding solutions and hydration bags. For two residents, the tube feeding solutions and kangaroo flush bags were not labeled with the date and time of initiation, contrary to facility policy and standard practice. The Director of Nursing confirmed that the facility's standard is to label all tube feeding solutions and hydration bags with the date and time they are started. The affected residents had significant medical conditions, including cerebral palsy, cognitive communication deficits, respiratory failure, Parkinson's disease, and cancer, and were dependent on staff for all care needs.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
A female resident with a history of stroke resulting in right-sided paralysis, blindness in one eye, and total dependence on staff for daily care was admitted to the facility. The resident had active orders for two muscle relaxants: Methocarbamol 500 mg three times daily (later increased to 750 mg in the morning) and Baclofen 10 mg three times daily. Both medications were administered concurrently, as documented in the electronic medication administration record. Hospital records indicated that the resident became somnolent and unarousable after receiving both medications, and emergency department staff reported that the facility had been giving both muscle relaxants at the same time. The facility's Director of Nursing confirmed that the error was not recognized by nursing staff, and the prescriber had not discontinued Methocarbamol when Baclofen was started.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure injuries for a resident, resulting in serious infection and delayed wound healing. The resident was admitted with multiple health conditions, including chronic kidney disease, congestive heart failure, and muscle weakness, and was identified as being at risk for pressure ulcers. Despite this, the initial assessments did not document any existing pressure ulcers or skin conditions. However, within a short period, the resident developed multiple unstageable pressure wounds on both feet, which were not promptly or adequately addressed. Observations and interviews revealed that the resident's feet were not properly elevated, and the standard pillow used for elevation was ineffective, leading to the resident's heels resting directly on the mattress. The facility's care plan included interventions such as cueing the resident to reposition, but these were insufficient to prevent the development of pressure injuries. The resident reported difficulty participating in physical therapy due to the wounds, which was a setback in their recovery process. The facility's documentation and treatment of the wounds were inconsistent and delayed. The resident's wounds were not evaluated by a wound care consultant until three weeks after the consultation was requested, and there was a lack of appropriate treatment orders for the open wounds. Additionally, when the resident showed signs of sepsis, a wound culture was not ordered, and the empiric antibiotic therapy may not have been appropriate. The facility's failure to implement effective pressure-reducing interventions and timely wound care contributed to the worsening of the resident's condition.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident reviewed for infection control. The policy effective from April 1, 2024, required the use of EBP in addition to Standard Precautions for residents with infections or colonization with CDC-targeted multidrug-resistant organisms (MDROs), or those with wounds or indwelling medical devices. The policy specified that signage should be placed on the resident's door and Personal Protective Equipment (PPE) should be readily available to staff. However, during observations, no signage or PPE were available for the resident, and staff did not don the required PPE during high-contact care activities. The resident had unstageable wounds on both feet, with dressings that were saturated with drainage. During a dressing change, the Registered Nurse (RN) did not wear a gown, which was required for residents needing EBP. The resident's care plan and order recap report did not reflect the need for EBP. An interview with the RN revealed a lack of awareness about the necessity of EBP for the resident's wound care, indicating a gap in staff training and implementation of the facility's infection control policy.
Failure to Administer Medications Post-Dialysis
Penalty
Summary
The facility failed to provide daily medications for a resident undergoing dialysis, resulting in the resident not receiving their prescribed medications three times a week. The resident, who has diagnoses including hemiplegia, hemiparesis, gastroparesis, and end-stage renal disease, was not administered their morning medications on days they attended dialysis sessions. These sessions occurred every Tuesday, Thursday, and Saturday, and the resident typically returned to the facility around noon. Despite this schedule, the facility did not have orders for dialysis in the resident's records, and the medications were not administered after the resident's return. The Medication Administration Records (MAR) for August, September, and October revealed that the resident missed multiple doses of various medications, including those for blood pressure, bipolar disorder, acid reflux, allergies, iron supplementation, constipation, anxiety, lactose intolerance, and antiemetic purposes. Interviews with the Director of Nursing and Assistant Director of Nursing indicated a lack of awareness regarding the missed doses and the absence of physician notification. The facility did not provide the resident's daily medications after dialysis, leading to the deficiency noted in the report.
Inadequate PEG/J Tube Care Leads to Repeated Clogging Incidents
Penalty
Summary
The facility failed to ensure proper care and maintenance of a Percutaneous Endoscopic Gastric/Jejunum (PEG/PEG/J) tube for a resident, resulting in multiple incidents of tube clogging and several emergency department visits. The resident, who had diagnoses including hemiplegia, gastroparesis, and end-stage renal disease, experienced significant issues with the PEG/J tube, including abdominal distention and bile leakage. Despite hospital discharge instructions to flush the tube with 50 mL of warm water after all tube feeds and medications, the facility did not implement these instructions in a timely manner, leading to repeated clogging incidents. The facility's records revealed a lack of documentation and education for nursing staff regarding the care of the resident's PEG tube. There were multiple instances where the tube became clogged, and the facility failed to follow hospital instructions to prevent clogging, such as using liquid medications and ensuring proper flushing techniques. The resident's family and hospital staff repeatedly provided instructions to the facility, but these were not effectively communicated or implemented by the nursing staff. Interviews with facility staff, including a registered nurse and the Assistant Director of Nursing, highlighted a lack of knowledge and training regarding PEG/J tube care. The registered nurse admitted to not knowing about the availability of a clot buster medication and not having received a skills competency evaluation. The Assistant Director of Nursing acknowledged that the facility did not have complete hospital records and that the nursing staff was not informed of hospital instructions. This lack of communication and training contributed to the ongoing issues with the resident's PEG/J tube care.
Inadequate Nursing Competency in PEG/PEGJ Tube Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to care for residents with Percutaneous Endoscopic Gastric/Jejunum (PEG/PEGJ) tubes, leading to repeated incidents of clogged tubes and multiple hospital visits for one resident. The review of nursing staff files revealed that none of the five nursing staff members had current competency skills and assessments related to PEG/PEGJ tube care. This lack of training and competency resulted in the resident experiencing several instances of clogged tubes, requiring emergency department visits for replacement or unclogging. The resident in question had significant medical conditions, including hemiplegia, gastroparesis, and end-stage renal disease, and relied on a PEG/PEGJ tube for nutrition. Despite the resident's complex needs, the nursing staff, including RN I, lacked the necessary training to manage the PEG/PEGJ tube effectively. RN I admitted to not knowing how to properly manage the tube, which led to a split tube due to excessive pressure and ineffective use of medication to unclog the tube. The Assistant Director of Nursing confirmed that RN I was re-educated on PEG/PEGJ tube care after these incidents, but no other nurses received similar education.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of an appropriate infection surveillance system for tracking and trending infections. During an interview and record review, it was revealed that the Director of Nursing (DON) and the Infection Preventionist/Assistant Director of Nursing (ADON) did not have a current infection control tracking report for July and August 2024. The ADON was unable to provide a current list of residents on antibiotics and admitted to difficulties in using the new infection control system. Additionally, the facility's mapping of infections did not correlate with the resident infection line listing, and there was no tracking of employee illnesses despite a high number of staff call-offs due to sickness. The facility's infection prevention program was further compromised by inadequate hand hygiene practices during a wound assessment. An LPN was observed assessing a resident's skin condition without changing gloves or performing hand hygiene after touching contaminated areas. The LPN acknowledged the failure to remove gloves and perform hand hygiene after assessing the resident's anal area, which could potentially lead to cross-contamination and infection spread. The facility's infection prevention policy, last revised in October 2023, outlines the need for surveillance of infections, implementation of control measures, and prevention of infections. However, the facility did not adhere to these guidelines, as evidenced by incomplete data collection, lack of infection tracking, and inadequate hand hygiene practices. The failure to maintain a comprehensive infection control program and ensure proper hand hygiene during resident care poses a risk to the health and safety of all residents and staff.
Failure to Designate Legal Surrogate for Resident
Penalty
Summary
The facility failed to designate a legal surrogate for healthcare decision-making for a resident who was reviewed for advance directives. The resident was admitted to the facility and was determined by two physicians to be incapable of making her own informed medical decisions. Despite this, the facility's electronic medical records did not show any legal surrogate appointed to represent the resident. During an interview, the Director of Social Services reported that the resident's daughter, who frequently visits, was supposed to provide paperwork proving her status as the legal guardian but had not yet done so. The Director expressed concern over the lack of appropriate documentation and indicated the need to pursue a court-appointed guardian if necessary.
Failure to Obtain Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the responsible party for a cognitively impaired resident, who was receiving antipsychotic medication, was informed of the risks and benefits associated with the medication and had consented to its administration. The resident, who was admitted with diagnoses including bipolar disorder and dementia with psychotic disturbance, had a Power of Attorney (POA) in place for medical decisions. Despite the presence of a doctor's order for the antipsychotic medication Lurasidone, there was no documentation in the Electronic Medical Record (EMR) indicating that the POA had been informed or had consented to the medication's use. During the survey, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were unable to provide documentation that the POA had been informed of the risks and benefits or had consented to the medication at the time it was started. Although a physician's note dated several months after the medication's initiation mentioned a risk/benefit analysis, it did not confirm that the POA had been informed or had consented. As of the survey's conclusion, no further documentation was provided to address this deficiency.
Failure to Update Care Plan for Resident's Active Skin Condition
Penalty
Summary
The facility failed to update the care plan for a resident with an active skin condition, resulting in the potential for inconsistent care. The resident, who was admitted with diagnoses including dementia and diabetes, was cognitively intact as indicated by a BIMS score of 15. Despite being treated for a leg infection, the care plan only noted a potential for impaired skin integrity and did not reflect the active condition. This oversight was discovered during a review of the care plan, which had not been updated since June 2023. Interviews with facility staff revealed a breakdown in communication and responsibility for updating care plans. The unit manager, who typically handled updates, had recently left, and the responsibility was believed to have shifted to the DON and MDS nurse. However, the ADON confirmed that the infection had not been discussed in clinical meetings, and the PA had not communicated the treatment to the interdisciplinary team, only notifying a floor nurse about the initiation of antibiotics. The facility's policy required care plans to be updated with significant changes, which was not adhered to in this case.
Failure to Monitor Resident Conditions and Skin Care
Penalty
Summary
The facility failed to properly assess, monitor, document, and notify the physician of changes in condition for a resident with chronic kidney disease and an overactive bladder, leading to the resident's hospitalization. The resident's family observed signs of distress and requested a urinary tract infection (UTI) test, but the facility did not promptly obtain a physician's order or conduct the necessary assessments. The resident exhibited symptoms of anxiety, confusion, and incontinence, yet vital signs were not documented, and the physician was not notified. The facility's failure to change the resident's foley catheter as ordered further contributed to the risk of infection. Another deficiency involved the facility's failure to identify and treat skin conditions for a resident with dementia and diabetes. Despite a cognitive assessment indicating the resident was intact, the resident reported painful skin issues that had not been evaluated. Upon examination, the resident had reddened and raw areas on the inner thighs, abdominal folds, and near the anus, which had not been identified during weekly skin assessments or daily care. The Physician's Assistant was unaware of these conditions, indicating a lack of communication and documentation by the nursing staff. The facility's policies on skin management and wound care were not followed, as evidenced by the lack of documentation and failure to notify medical providers of new skin conditions. The Nursing Home Administrator confirmed the absence of records regarding the resident's skin concerns prior to the date of the survey. This oversight resulted in the potential for deterioration of the resident's skin conditions and compromised their physical, mental, and psychosocial well-being.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess and monitor the nutritional status of a resident who experienced significant weight loss. The resident, admitted with diagnoses including dementia, morbid obesity, vitamin deficiency, and dysphagia, lost 33 pounds (12.3%) within the first month of admission and a total of 62 pounds (22.69%) over several months. Despite the significant weight loss, the facility's electronic medical records (EMR) did not show consistent monitoring or timely interventions, such as referrals to a medical provider. The care plan did not specifically address the weight loss, and although a nutritional supplement was added, there was no evidence of ongoing evaluation or adjustment of the care plan. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that they considered the weight loss desirable, yet they failed to provide documentation supporting this claim. A Registered Dietician's progress note from July indicated significant weight loss triggers but did not include a referral to a medical provider. The EMR review from October to August showed a lack of ongoing nutritional monitoring or documentation of referrals for the resident's weight loss. As of the survey exit, no further documentation was provided by the facility to demonstrate that the weight loss was appropriately addressed.
Failure to Verify Feeding Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure proper verification of feeding tube placement before administering medication to a resident, as per professional standards and facility policy. The resident in question, identified as Resident #72, was admitted with diagnoses including dementia and dysphagia, necessitating the use of a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. The facility's policy required verification of tube placement by aspirating stomach contents before medication administration, a step that was not followed during the observed incident. During an observation, a Licensed Practical Nurse (LPN) administered medication to Resident #72 via the PEG tube without verifying the tube's placement by aspirating stomach contents. The LPN admitted to checking the placement earlier in the day but did not do so before the medication administration observed. Instead, the LPN relied on listening for air bubbles while flushing the line, which is not in accordance with the facility's policy. Interviews with the LPN and the Assistant Director of Nursing revealed a lack of adherence to the facility's policy and a lack of clarity regarding the procedure for verifying PEG tube placement. The facility's policy, aligned with professional guidelines, emphasizes the importance of verifying tube placement to prevent complications such as aspiration pneumonia, which can occur if the tube is not correctly positioned in the stomach or small intestine.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to identify and address a significant weight loss in a resident, referred to as R38, who was admitted with diagnoses including dementia, morbid obesity, vitamin deficiency, and dysphagia. From the date of admission, R38 experienced a weight loss of 33 pounds, or 12.3%, within less than a month, and a total weight loss of 69.8 pounds, or 25.85%, by June of the following year. Despite this significant weight change, there was no documentation in the Electronic Medical Record (EMR) indicating that the weight loss was identified and reported to the Medical Provider. Progress notes from medical provider encounters inaccurately stated that there was no weight loss, which was inconsistent with the resident's weight history. The facility's documentation did not reflect any timely evaluation or intervention by the Medical Provider regarding the resident's weight loss. Although a nutritional supplement was added to the resident's diet in December, there was no evidence of consistent monitoring or referral to the Medical Provider. The Registered Dietician's progress note, dated eight months after the initial nutrition note, acknowledged significant weight loss triggers but also failed to indicate a referral to the Medical Provider. The facility did not provide additional documentation to show that the significant weight change had been adequately monitored or addressed by the Medical Provider by the time of the survey exit.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to address pharmacy recommendations for two residents, leading to deficiencies in medication management. Resident R38, who was admitted with diagnoses including dementia, dysphagia, and bipolar disorder, had pharmacy medication reviews conducted in January and July of 2024. However, these recommendations were not reviewed by the physician. Specifically, a recommendation from January 2024 for lab values to be obtained and a July 2024 recommendation for an updated Abnormal Involuntary Movement Scale (AIMS) assessment were not acted upon until requested by the surveyor. Similarly, for Resident R59, who was admitted with a history of stroke, pharmacy medication reviews in July and August of 2024 were not reviewed by the physician. Recommendations included reducing the dosage of an anticoagulant and questioning the need for a nutritional supplement based on lab values. These recommendations were not reviewed by the physician until prompted by the surveyor. The facility's policy requires that pharmacy recommendations be reviewed and acted upon by the attending physician, but this process was not followed, leading to the identified deficiencies.
Incomplete Medical Records for Resident's Treatment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to potential miscommunication and an unclear picture of the resident's healthcare status. Specifically, the electronic health record (EHR) for a resident showed an antibiotic order to treat the resident's lower legs, but there was no further documentation from nursing staff or medical providers regarding the skin condition. This lack of documentation was identified during a review of the resident's EHR. Interviews conducted during the investigation revealed that the Assistant Director of Nursing (ADON) acknowledged the absence of documentation from the Physician's Assistant (PA) regarding the resident's lower leg infection and evaluation. The PA confirmed that she began treating the resident with antibiotics for chronic lower leg venous stasis dermatitis but had not yet completed the documentation in the EHR. The facility's policy on documentation expectations requires that all facts and pertinent information related to treatment and resident condition be documented in a timely and organized manner.
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What surveyors actually found near you
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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 Hudsonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Jamestown | 2.6 mi | ★★★★★ | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 6 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Wyoming | 6.2 mi | ★★★★★ | 0 | 0 |
| Allendale Nursing And Rehabilitation Community | 7 mi | ★★★★★ | 18 | 0 |
| Heritage Nursing And Rehabilitation Community | 8.1 mi | ★★★★★ | 19 | 0 |
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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 October 2026) and official state health department websites.