Medilodge of Cheboygan

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assessment, monitoring, and care per facility policy and professional standards for treatment with a nebulizer for one Resident (Resident #2) of one resident reviewed for inhaled medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure follow-up to a change in condition according to professional standards of practice for two Residents (#11 and #75) of three resident's reviewed for change in condition. This deficient practice resulted in the potential for complications and worsening of condition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure wound care was completed according to physician order and professional standards of practice for one Resident (#6) of one resident reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor fluids and provide the diet as ordered for one Resident (R99) of three residents reviewed for fluid concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for dialysis, monitor a dialysis access site, report dialysis concerns to the physician, care plan potential fluid volume overload, and adhere to physician-prescribed fluid restrictions for one Resident (#8) of one resident reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately dispense insulin to two Residents (Residents #2, #11) of seven residents reviewed for medication administration resulting in 2 errors in 34 opportunities for error and a 5.88% medication error rate. Findings Include: On 4/13/26 at 7:39 PM, Registered Nurse (RN) B was observed administering insulin to Resident #2 (R2) and held the subcutaneous injection site for six seconds. On 4/13/26 at 7:40 PM, an interview was conducted with RN B regarding how long she was to hold the injection site and replied, Ten seconds. RN B was made aware she only held the needle in place for six seconds. RN B remarked, I must have counted fast .On 4/13/26 at 8:03 PM, RN C was observed administering insulin to Resident #11 (R11) and held the subcutaneous injection site for 5 seconds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Identify appropriate required Transmission Based Precautions (TBP),Obtain a physician's order timely for isolation precautions,Appropriately apply and remove personal protective equipment (PPE),Utilize PPE when indicated, and;Discontinue an antibiotic medication or document justification for continuing antibiotic medication when test results were negative for Resident #2, affecting three Residents (#2, #16, & #12) of six residents reviewed for infection prevention and control.

Inspectors wroteBased on interview and record review, the facility failed to offer and administer COVID vaccinations to two Resident (#2 & #4) of five residents reviewed for immunizations.

Inspectors wroteThis deficiency pertains to intake #2661622Based on interview and record review, the facility failed to protect the right of one Resident (R1) to be free from physical and verbal abuse by a staff member of three residents reviewed for abuse. This deficient practice resulted in psychosocial harm including feelings of humiliation and fear based on the reasonable-person concept.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safe and effective infection prevention and control (IPC) practices for eight residents (#10, #30, #14, #59, #50, #67, #6, and #65) of ten residents reviewed for IPC to prevent the potential transmission of communicable diseases and infections as evidenced by failure to: 1. Maintain room doors closed for residents with COVID-19. 2. Appropriately sanitize and disinfect contaminated medical equipment. 3. Remove Personal Protective Equipment (PPE) prior to exiting the room of a resident with COVID-19 on Transmission-Based Precautions (TBP). 4. Prepare and handle medications in a manner to prevent contamination. 5. Ensure care plans were initiated for residents with COVID-19. 6. Ensure physicians' orders for were obtained before placing residents in TBP. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respectful treatment and a dignified dining experience for three Residents (#18, #20, and #58) of five residents reviewed for residents' rights. This deficient practice resulted in the potential for feelings of frustration, embarrassment, and humiliation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately dispose of contaminated medications for three Residents (#61, #50, and #47) of eight residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Residents (#47, & #224) of eight residents reviewed for medication administration received the correct dosages of prescribed medications. This deficient practice resulted in a medication error rate of 9.38 % with 3 medication errors detected in 32 opportunities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as prescribed for two Residents (R224 and R47) of eight residents reviewed for medication administration. This deficient practice resulted in R224 experiencing excruciating pain and the potential for R47 to experience increased anxiety.

Inspectors wroteThis citation pertains to intakes MI00147076 and MI00147197. Based on observation, interview and record review, the facility failed to ensure appropriate assessments and communication for change in condition for one Resident (#2) of three residents reviewed for change in condition, resulting in harm when Resident #2 was transferred to the hospital for mental status changes, found to have a severe wound infection and underwent subsequent intravenous antibiotic administration and surgical intervention.

Inspectors wroteThis citation pertains to intake MI00146968. Based on interview and record review, the facility failed to provide written notification for a facility-initiated discharge, including the reason, effective dates and right to appeal to the resident's representative and the Office of the State Long-Term Care (LTC) Ombudsman for one Resident (#1) of three residents reviewed for transfer or discharge, resulting in the resident and resident's representative being uninformed of their rights, an unnecessarily extended hospital stay and the potential for inappropriate discharge.

Inspectors wroteIntake #MI00143052 Based on interview and record review the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for one (resident #3) of one resident reviewed for diabetes management, resulting in diabetic ketoacidosis (emergent condition resulting from prolonged elevated blood sugar levels), hospitalization and death.

Inspectors wroteIntake #MI00143052 Based on observation, interview, and record review the facility failed to notify a physician of pressure ulcer condition worsening for one resident (Resident #3) of three residents reviewed for pressure ulcers. This deficient practice resulted in the potential for wound infection and worsening of pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignified and respectful treatment for one Resident (R11) of three residents reviewed for dignity. This deficient practice resulted in an undignified shower experience and disrespectful treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were updated and revised appropriately for two Residents (R3 and R45) out of 15 Resident care plans reviewed. This deficient practice resulted in care plans which did not reflect resident needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop timely care plan interventions and implement physician-ordered pressure-alleviation devices to promote healing of wounds for one Resident (R2) of three residents reviewed for wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to promote the healing of a pressure injury for one Resident (R23) of three residents reviewed for pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was served as prescribed for 3 of 3 residents (R13, R33, and R40) reviewed for therapeutic diets. This deficient practice resulted in the potential for health complications.