Medilodge of East Lansing

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively maintain the physical plant effecting 69 residents resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for antidepressant medication use for one (R11) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of advance directives for one (R13) of two reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (Resident #35) out of three residents was up able to regularly attend activities. Findings Included:Per the facility's face sheet Resident #35 (R35) was admitted to the facility on [DATE]. Diagnoses included history of traumatic brain injury and persistent vegetative state. Review of a Brief Interview of Mental Status (BIMS) dated 11/10/2025, revealed R35's BIMS score was zero out of 15 which indicated R35 had no cognitive ability to respond to stimuli or voice his needs. In an observation on 1/07/2026 at 3:34 PM, R35 was observed in bed, but was never observed today to be out of bed and sitting in the Broda chair that was observed in R35's room. The Broda chair was observed to have several wedges and blankets laying on the seat. In an observation on 1/08/2026 at 8:39 AM, R35 remained in bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently and timely address Monthly Medication Regimen Review recommendations for one (R37) of five reviewed. On 1/7/26 at 9:04 AM, R37 was observed sitting up in his bed with clear speech. He reported needing a swallow study and being thirsty. A review of the clinical record revealed R37 was admitted into the facility on 8/2/2025 with the most recent re-admission on [DATE], with diagnoses that included: tracheostomy, anxiety, and need for assistance with personal care. According to the Minimum Data Set (MDS) assessment dated [DATE], R37 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). A review of R37's physician orders for his diet revealed an NPO order (nothing by mouth) dated 10/21/2025 through current. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (R9) of three reviewed was able to understand and consent to the binding arbitration agreement.

Inspectors wroteThis citation pertains to intact 2655825Based on observation, interview, and record review the facility failed to prevent significant weight loss in two residents (#12, #16) of three residents reviewed for weight loss. Findings Included: [...]

Inspectors wroteThis citation pertains to intact 2655825Based on observation, interview, and record review the facility failed to follow physician orders for the administration of tube feeding solution for one resident (#12) out of three residents reviewed resulting in the harm of significant weight loss. Findings Included: [...]

Inspectors wroteThis Citation Pertains to Intake #2627443, 2634124, 2642694, 2662031, 2668275. Based on observation, interview and record review the facility failed to ensure sufficient nursing staff and call lights were responded to in a timely manner for 3 of 3 residents reviewed (Resident #2, Resident #4 and Resident #7). Resident #4 (R4): Review of the medical record revealed R4 was admitted to the facility 10/28/29 with diagnoses that included quadriplegia, chronic respiratory failure, neuromuscular dysfunction of bladder (nerve damage of the bladder), sever protein calorie malnutrition, tracheostomy, colostomy, iron deficiency, stage 3 pressure ulcer, asthma, and insomnia. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteThis Citation Pertains To Intake # 2631073, 2666145, 2655825, 2666019 and 267649Based on observation, interview and record review the facility failed to provide showers/bathing on a routine basis to maintain cleanliness and hygiene for 2 residents (Resident #2 and Resident #12) of four reviewed.

Inspectors wroteThis Citation Pertains to Intake #'s 2677649 and 2666019. Based on observation, interview and record review, the facility failed to monitor and treat constipation for two of three residents reviewed (Resident #12 and # 15) resulting in hospitalization for Resident #12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage of medication, medications observed in hall unattended, for one resident (#18) out of a facility census of 68 residents. Findings Included:Resident #18 (R18)Review of the medical record revealed R18 was admitted to the facility 07/22/2024 with diagnoses that included stroke, hypertension, chronic pain, bradycardia, bilateral hearing loss, dementia, post-traumatic stress disorder, prostate cancer, gastro-esophageal reflux disease, adjustment disorder with depressed mood, constipation, and restless leg syndrome. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/25, revealed R18 had a Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. During the initial tour of the facility on 12/01/2025 at 09:14 a.m. [...]

Inspectors wroteThis citation pertains to intake 2597662. Based on observation, interview and record review, the facility failed to ensure medications were administered per physician's orders for one (R1) of three reviewed.

Inspectors wroteThis citation pertains to intake 2597662. Based on observation, interview and record review, the facility failed to provide respiratory care according to physician's orders for one (R1) of three reviewed.

Inspectors wroteThis citation pertains to intake number MI00151442 and MI00151852 Based on observation, interview, and record review the facility failed to provide for three out of three residents (Resident #105, #106, #111) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds, osteomyelitis, and hospitalization. Findings Included: Review of the facility Matrix, dated 4/8/25, the facility census was 69 and they had nine current residents with pressure ulcers and three had facility acquired pressure wounds. Review of two complaints received by the State Agency alleged the facility failed to prevent worsening of pressure ulcers for R105 and R106, who was known high risk for skin breakdown. [...]

Inspectors wroteThis citation pertains to intake MI00151358, MI00150638 and MI00151852. Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL's), including bathing/showering for four dependent resident (R103, R104, R106, and R110) reviewed of ADL care, resulting in increased worsening of pressure wounds and likelihood of feelings of worthlessness, disrespect and the potential for infection.

Inspectors wroteThis citation pertains to intakes: MI00151418, MI00151694, MI00151358, MI00150699, MI00150638, MI00151442, and MI00151852. Based on observation, interview and record review, the facility failed to ensure sufficient levels of nursing staff to meet resident needs and supervision for seven residents (Resident R102, R103, R104, R105, R106, R110 and R111) and per resident council with the potential for unmet care needs and facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation refers to intake MI00151694 and MI00150699. Based on interview and record review, the facility failed to provide adequate supervision for resident with known high risk for falls and implement care planned interventions to prevent fall injuries for 1 residents (R102) out of 3 residents reviewed for falls, resulting in R102 fall with injury requiring emergency room treatment and hospital admission.

Inspectors wroteThis citation pertains to intake number MI00149947 Based on observation, interview, and record review the facility failed to ensure for one out of seven residents (Resident #7) a comprehensive care plan, including revisions, were in place for prevention and promotion of pressure ulcer healing. Findings Included: Per Resident #7's (R7) electronic medical record (EMR) R7 was admitted to the facility on [DATE]. Diagnoses included right and left knee contractures. In an observation, and attempt to interview, on 2/27/2025 at 9:46 AM, R7 was observed in bed. R7 was observed to have contractures to both arms, both hands and fingers, neck, and was not able to communicate. R7's feet/heels were observed to be lying on the mattress with nothing in between R7's feet/heels and the mattress in order to offload the pressure from the mattress. [...]

Inspectors wroteThis citation pertains to intake number MI00149947. Based on observation, interview, and record review the facility failed to provide for one out of three residents (Resident #7) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds. Findings Included: Per Resident #7's (R7) electronic medical record (EMR) R7 was admitted to the facility on [DATE]. Diagnoses included right and left knee contractures. In an observation, and attempt to interview, on 2/27/2025 at 9:46 AM, R7 was observed in bed. R7 was observed to have contractures to both arms, both hands and fingers, neck, and was not able to communicate. R7's feet/heels were observed to be lying on the mattress with nothing in between R7's feet/heels and the mattress in order to offload the pressure from the mattress. [...]

Inspectors wroteThis citation pertains to intake MI000148211. Based on interview and record review the facility failed to ensure infection control surveillance was monitored, mapped and documented monthly to maintain a safe and sanitary environment for all 62 residents who resided at the facility. Findings Included: On 12/17/2024 via email to Administrator A a request was sent to provide the facility's August through December 2024 Infection Control line listing with the color coded maps of each unit. Upon receiving the requested infection control documents on 12/17/2024, it was revealed that only August, September, and October 2024 line listings (residents listed that have an infection, what the organism is, and the antibiotic if applicable) were received. Also the only map that was received was for the month of September 2024. [...]

Inspectors wroteThis citation pertains to intake number MI00148475. Based on interview and record review the facility failed to ensure one of four residents (Resident 2) had a person-centered baseline care plan developed, and implemented with appropriate interventions and revisions as needed. Finding Included: Review of Resident #2's (R2) face sheet it was revealed R2 was admitted to the facility on [DATE] for a 10 day respite with expected discharge on [DATE]. R2 no longer resided at the facility at the time of the onsite survey. Review of R2's admission fall risk assessment dated [DATE], revealed as question to be answered Yes or No if R2 had displayed any of the following behaviors: was a high risk for falls. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for three (Resident #36, #59, and #68) of 17 reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement comprehensive care plans for 3 (Resident #4, 22 and 28) of 17 reviewed, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the timely collection of an ordered urinalysis (urine test) for one (Resident #60) of two reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to promote pressure ulcer healing and prevent the worsening of pressure ulcers for one resident (R4) of three residents reviewed for pressure ulcers, resulting in the potential for delayed wound healing and/or the worsening of wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician order for oxygen for one resident (R4) out of four residents reviewed for respiratory care.

Inspectors wroteThis citation pertains to Intake MI00145607 Based on interviews and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one (R3) of 3 residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake MI00145078. Based on interview and record review, the facility failed to ensure the physician was notified of a change in treatment orders when one resident (Resident #3) did not transfer to the emergency room (ER) for bleeding, as ordered.

Inspectors wroteThis citation pertains to intake MI00145078. Based on interview and record review, the facility failed to routinely assess and monitor a change in condition for one (Resident #3).

Inspectors wroteThis citation pertains to intakes MI00144740 and MI00145260. Based on interview and record review, the facility failed to ensure appropriate orders to treat pressure ulcers for one (Resident #2) of four reviewed.

Inspectors wroteThis citation pertains to intake MI00143527 Based on observation, interview, and record review, the facility failed to prevent the development of a medical device related pressure ulcer for 1 (Resident #1) of 3 residents reviewed for pressure ulcers resulting in the development of a facility acquired deep tissue injury (DTI-intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) with the potential for delayed wound healing and/or worsening pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Level II Screening for Mental Illness/Intellectual/Developmental Disability/Related Condition Exemption Criteria Certification or refer to Community Mental Health for an OBRA Level II evaluation for one (Resident #60) of one reviewed for Preadmission Screening/Annual Resident Review (PASARR), resulting in the potential for lack of appropriate mental health treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement nutrition interventions for one (Resident #54) of three reviewed, resulting in the potential for further weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor pharmacy recommendations upon readmission from the hospital for three (Resident #16, #20 and #36) of five reviewed for pharmacy medication regimen reviews, resulting in the potential for unnecessary medications, medication interactions and adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to justify the continued PRN (as needed) use and/or provide a duration of use of a psychotropic medication for two (Resident #16 and Resident #36) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (Resident #25) was prepared for a CT scan out of one reviewed, resulting in delayed services and frustration and anger.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform acceptable infection control standard while performing suprapubic catheter care for one resident (#36) of one resident reviewed for suprapubic catheter care resulting in the potential to spread infection to other staff and residents. Findings Included: [...]