Medilodge of Campus Area

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the code status was accurate and reflective of the resident's wishes for one (R7) of two reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a care conference after admission for one (R7) of two reviewed.

Inspectors wroteThis citation pertains to Intake 2989711. Based on observation, interview, and record review, the facility failed to 1) identify and treat a new wound for one (R70) and 2) treat earwax buildup for one (R58) of 17 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain vision services for one (R7) of two reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label medications in one of two medication carts reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain dental services for two (R7 and R58) of two reviewed.

Inspectors wroteThis citation pertains to intake MI000151964. Based on interview and record review, the facility 1) failed to assess and monitor and 2) follow physician orders for one (Resident #500) of three reviewed for quality of care, resulting in a delay in recognition and response to a significant change in condition which progressed to a cardiac arrest and subsequent poor outcome, including CPR, hospitalization, and ultimately comfort care status. Resident #500 (R500) A review of the medical record reflected that R500 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypotension, chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. Findings Include: Review of the facility policy entitled QAPI Plan with a date of implementation of 10/24/22 demonstrated in the purpose statement, It is the policy of this facility to systemically collect date as part of the QAPI program to ensure the care and services it delivers meet acceptable standard of quality in accordance with recognized standard of practice. Key components, listed in the policy, include: 1. Tracking and measuring performance 2. Establishing goals and thresholds for performance improvements 3. Identifying and prioritizing quality deficiencies 4. Systematically analyzing underlying causes of system quality deficiencies. 5. [...]

Inspectors wroteThis citation pertains to MI00146912, MI00150426 Based on observation, interview, and record review the facility failed to effectively clean and maintain the physical plant for resident rooms 200, 211,214, 301,303, 400 and maintain a homelike environment regarding noise and phone usage for Resident #318 and Resident Council. Findings Included: On 02/25/2026 at 08:50 a.m. in room [ROOM NUMBER] bathroom the laminate that covered the counter of the sink appeared to be coming off the countertop. Gripper strips only the right side of the bed for 200-1 were observed to be torn and coming off the floor. On 02/25/2025 at 09:13 a.m. room [ROOM NUMBER]-2 was observed to have a hole in the closet door. On 02/25/2025 at 10:19 a.m. observed room [ROOM NUMBER] to be unclean. Dust balls were observed on the floor. [...]

Inspectors wroteOn 02/25/25 09:11 AM, during an interview with Certified Nursing Assistant (CNA) W reported that today she was assigned 13 residents, will at times have 16 residents which was very difficult but impossible to complete all the assigned tasks in caring for that many residents. During an interview with CNA X on 02/25/25 at 09:37 AM, it was reported 13 residents were assigned today. CNA X elaborated on many occasions closer to 20 residents have been assigned, and it was not possible to provide the care needed for 20 residents. On 02/27/25 at 10:26 AM, CNA's E and K reported they normally have 12 or 13 residents assigned to care for but the facility experiences a lot of staff that call in sick and when this happens they will have 20 residents assigned to them and this was not doable. [...]

Inspectors wroteThis citation pertains to Intake: MI00149724, MI00150426 Based on observation, interview, and record review the facility failed to maintain preferred food temperature and acceptable palatability for three residents (R11, R41, and R318) out of ten residents reviewed for food palatability and food preferred temperatures. Findings Included: [...]

Inspectors wroteThis Citation Pertains to MI00146912 and MI00150426 Based on observation, interview and record review, the facility failed to preserve the dignity of 3 of 4 residents (Resident #2, #318, #32) reviewed for dignity and 4 of 5 residents for residents that attended the confidential group meeting.

Inspectors wroteBased on interview and record review the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for 5 of 5 residents that participated in the Resident Council (RC) meeting and Resident #2.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) were provided to two (R323 and R325) of three residents reviewed for beneficiary notification, resulting in the potential for residents and/or representatives to be uninformed of the potential private pay charges of continued services at the facility and inability to file an appeal.

Inspectors wroteThis citation pertains to Intake: MI00150426 Based on observation, interview, and record review the facility failed to accurately record and make a prompt effort to resolve grievances for one resident (#318) of one resident reviewed for grievances. Findings Included: Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#6) of 16 residents reviewed for accurate assessments. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to notify the local state mental health authority of Pre-admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) changes for one (Resident #33) of two reviewed for PASARR.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for one resident (#32) of 16 reviewed. Findings Included: Resident #32 (R32) Review of the medical record revealed R32 was admitted to the facility 04/18/2019 with diagnoses that included multiple sclerosis, paraplegia (paralysis that occurs in the lower half of the body), neuromuscular dysfunction of bladder, type 2 diabetes, obesity, diabetic neuropathy (nerve damage caused by diabetes), cardiomegaly (enlarge heart), muscle spasm, anemia (low red blood cells), hyperlipidemia (high fat content in blood), chronic obstructive pulmonary disease (COPD), chronic pain, altered mental status, metabolic encephalopathy (impaired brain function), insomnia, edema, anxiety, major depression, migraine, and gastro-esophageal reflux. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to include one resident (R#29) in care plan development of 16 residents reviewed for participation in care planning.

Inspectors wroteThis citation pertains to intake: MI00150426 Based on observation, interview, and record review the facility failed to follow physician orders for three residents (R11-brace application, R41-prosthetic fitting appointment, and R318-medication administration time) of sixteen residents reviewed for quality of care. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide diabetic foot care to one (R47) of one reviewed for foot care, resulting in long toenails and discomfort.

Inspectors wroteThis citation pertains to intake: MI00150426 Based on observation, interview, and record review the facility failed to provide medication in a timely manner for one resident (R318) out of four residents reviewed for pharmacy services. Findings Included: Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented in the medical record the rationale for no changes to the medication review for one (Resident #4) of five reviewed.

Inspectors wroteResident #50 (R50) Review of the medical record revealed R50 admitted to the facility on [DATE] with diagnoses that included acute kidney failure. Review of the Physician's Order dated 2/11/25 revealed an as needed order for Tylenol Oral Tablet 325 MG (Acetaminophen). Give 2 tablet by mouth every 8 hours as needed for Elevated Temperature;Pain. Review of the Physician's Order dated 2/11/25 revealed an as needed order for Norco Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 4 hours as needed for pain. Review of these orders revealed no parameters for the maximum dose permitted for acetaminophen, and if given as ordered, would exceed the maximum dose of acetaminophen allowed. In an interview on 03/03/25 at 2:16 PM, Director of Nursing (DON) C agreed the ordered doses exceeded the prescribed parameter of 3000 mg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when two medication errors were observed from a total of 27 opportunities for one resident (R61) of three reviewed, resulting in a medication error rate of 7.41%.

Inspectors wroteResident 55 (R55) review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected R55 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) . On 02/25/25 at 08:36 AM, while entering R55's room alongside Social Service Director (SSD) N, R55 was observed in bed, there was a medication cup observed on R55's nightstand. The medication cup was observed to have 5 pills in the cup. R55 reported we woke her up at which time SSD N left the room. R#55 reported she was not woken up for breakfast or to take her medications. When queried if her medication were usually left at the bedside R55 reported yes sometimes. On 02/27/25 at 12:06 PM, during an interview with Assistant Director of Nursing (ADON) T reported there were no current residents in facility that were approved for self administration of medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to address dental need for one resident (resident #2) of 3 reviewed for dental services.

Inspectors wroteThis citation includes intake MI000150426 Based on observation, interview and record review, the facility failed to provide requested dietary items for three residents (R29, R60 and R319) of ten residents reviewed for food.

Inspectors wroteThis citation includes intake MI000150119 Based on observation, interview and record review, the facility failed to 1) ensure tracking and trending of employee illness; 2) implement timely Transmission-Based Precautions (TBP) for one COVID-19 positive resident (Resident #30) of one reviewed; and 3) ensure appropriate cleaning and storage of a CPAP (continuous positive airway pressure) mask for one (Resident #319).

Inspectors wroteBased on interview and record review, the facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for one (Resident #18) of five reviewed for immunizations.

Inspectors wroteBased on interview and record review, the facility failed to offer COVID-19 booster immunizations to three (Resident #6, #18 and #32) of five reviewed for immunizations.

Inspectors wroteThis citation pertains to intake MI00143189 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 (Resident #3) of 4 reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being

Inspectors wroteThis citation pertains to intake MI00143189 Based on observation, interview, and record review, the facility failed to timely identify, investigate, and report a staff to resident allegation of abuse to the abuse coordinator (the Nursing Home Administrator), and failed to timely report the allegation to the State Agency for 1 (Resident #3) of 4 residents reviewed for abuse, resulting in delayed identification, investigation, and reporting and the potential for further allegations of abuse to go unreported.

Inspectors wroteThis citation pertains to intake MI00143099 Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 1 (Resident #2) of 3 residents reviewed for ADLs, resulting in unmet care needs and the potential for a decline in emotional and physical health.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a significant medication error for one resident (#463) of four residents reviewed resulting in the potential for decreased efficacy of anticonvulsant medication resulting in the potential of seizure activity. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control guidelines for glucometer cleaning and handling of medication for four residents (#15, #17, #38, #463) of four residents during medication administration observation resulting in the potential to spread infection and blood borne pathogens. Findings Included: Resident #15 (R15) Review of the medical record revealed R15 was admitted to the facility 7/09/2022 with diagnoses that included type 2 diabetes, heart failure, hyperkalemia (high potassium), dementia, metabolic encephalopathy (brain disease), gastro-esophageal reflux, dysphagia (difficulty swallowing), personality disorder, psychotic disorder, cerebral infarction (stroke), mood disorder, and depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments for three (Resident #25, #41, #53) of 15 reviewed, resulting in inaccurate assessments and the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive plan of care for two residents (#18, #25) of 15 residents reviewed for planning of care resulting in the potential for unmet care needs or the potential for inadequate/inappropriate resident care. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ensure appropriate treatment and services for contracture management for one resident (#18) of two residents reviewed resulting in the potential for the development and worsening of contractures and pain. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician's orders and urology recommendations to attempt to restore continence for one (Resident #25) of one reviewed, resulting in the potential for continence status to not be restored to the extent possible.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician documented review of pharmacy recommendations/follow up occurred for 1 resident (Resident #6) of 5 residents reviewed resulting in the potential for medication side effects and/or unnecessary medications for residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication rate was less than 5% when eleven mediation errors were observed from a total of 35 opportunities for one resident (#463) of four residents reviewed for medication administration resulting in a medication error rate of 31.43% and resulting potential for adverse reactions, and/or side effects, and/or decrease drug efficacy. Findings Included: [...]