Medilodge of Frankenmuth

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility 1) Failed to 1) follow enhanced barrier precautions (EBP) for residents identified with qualifying medical needs, for one resident #6 (R6) of one resident; 2) Ensure that respiratory treatment and suctioning equipment were properly stored and maintained, for one (R6) of one residents; 3) Ensure that infection control rounding data collection and surveillance was performed for all residents residing in the facility; and 4) Ensure that appropriate glucometer disinfection was followed for one of three residents reviewed (Resident #29) for infection prevention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain cleanliness and ensure that appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for the spread of pathogens and contamination to the water supply, affecting all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were treated in a respectful and dignified manner to ensure timely assistance with care, that call lights were in reach, privacy and a homelike environment for a Confidential Group of Residents and Residents #6, #17, #67, and #83 from a sample of 41 residents reviewed. Findings Include: Confidential Group of Residents On 5/05/2026 at 11:01 AM, during an interview with a Confidential Group of Residents they verbalized their frustration with staff entering their rooms to answer call lights and then the staff say they will be back, shut off the call lights and leave and don't come back. The Confidential residents said, Why don't they take care of our needs while they are there; sometimes they will not be back at all if you complain about it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that HS (evening/nighttime) snacks were provided on a regular basis for a Confidential Group of Residents, resulting in residents verbalizing feelings of anger, and frustration. Findings Include: On 5/05/2026 at 11:01 AM, during a meeting with a Confidential Group of Residents, they said they were upset about the process for receiving a snack in the evening at bedtime. They said you had to fill out a blue form, that came on their meal tray, but you had to have the form returned to the kitchen by 2:00 PM or you didn't get a snack. The residents said they did not like this process, because you could change your mind about what you wanted or they might not have what you chose if someone else took it, also some of the resident's could not ask for or fill out the form. Some of the residents said they did not receive a snack. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the antibiotic stewardship program and standards of practice for 4 residents (#4, #18, #40, #59) of 4 residents reviewed, for antibiotic usage, resulting in four residents receiving antibiotics without appropriate clinical rationale.

Inspectors wroteBased on observation, interview and record review, the facility to follow standards of practice during medication administration for three of three residents reviewed (Resident #3, Resident #28, Resident #43) along with a confidential group of residents, resulting in resident complaints of not getting their medications correctly.

Inspectors wroteThis Citation Pertains to Intake Number 2992230. Based on observation, interview and record review, the facility failed to provide timely assistance with activities of daily living (ADL) including grooming and shaving for 2 residents (#9 and #12), of 2 residents reviewed for ADLs. Findings Include: Resident #9: Observation and interview on 05/04/2026 at 9:42 AM of Resident #9 was observed outside in the courtyard noted with chin whiskers of gray and black in color visible. Resident #9 stated that staff only shave her on shower days and would like it more often. Observation on 05/05/2026 at 11:52 AM of Resident #9 with whiskers today. seated in dining room. Observation on 05/05/2026 at 12:59 PM of Resident #9 and a visitor to go into the courtyard to sit in the sun outside. Resident chin Whiskers were visible again. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to date dressings and give consistent dressing changes for 2 residents (Resident #1, Resident #17) of 3 residents reviewed for wound care, resulting in prolonged healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) formula was administered as ordered for one resident (Resident #3) and the enteral feeding equipment was properly maintained for one resident (Resident #4) of 4 residents reviewed for enteral nutrition/feeding tubes. Findings Include: Tube Feeding: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Amyotrophic Lateral Sclerosis/ALS, dysphagia (difficulty swallowing), need for a feeding tube, COPD, diabetes, sleep apnea, heart disease, GERD and PTSD. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sanitary storage of respiratory equipment for 1 resident (Resident #3) of 3 residents reviewed for respiratory care. Findings Include:Resident #3: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Amyotrophic Lateral Sclerosis/ALS, dysphagia (difficulty swallowing), need for a feeding tube, COPD, diabetes, sleep apnea, heart disease, GERD and PTSD. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 5/04/2026 at 9:39 AM, Resident #3 was observed lying in his bed, awake and talkative. [...]

Inspectors wroteThis citation pertains to Intake Number 2993831. Based on observation, interview, and record review, the facility failed to ensure that nursing staff were reviewed for competency prior to caring for residents, for one of five staff reviewed for staffing education and competency.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the daily staff posting was accurate for all staff that provided care for all residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice for insulin administration and needle safety for one resident (Resident #29) of three residents reviewed for insulin administration, resulting in the likelihood of decreased dosage administered and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) Ensure that corrective action was taken when out-of-range temperatures were identified on medication refrigerator temperature logs for one of one medication refrigerator and 2) Discard discontinued or expired topical medications for two of two treatment carts reviewed for medication storage, creating the potential for compromised integrity of temperature-sensitive and topical medications.

Inspectors wroteThis citation pertains to Intake Number 2726226. Based on observation, interview and record review the facility failed to implement individualized interventions to address the dementia care needs of one resident (Resident #606) of six residents reviewed for dementia. Findings Include:Resident #606:On 4/6/2026 at 11:00 AM, a tour was completed of the locked memory care unit. We entered through the common room area where residents were observed at tables with two facility staff members. Once in the hallway there was no nursing staff observed. Upon entering room [ROOM NUMBER], a gentleman was observed sleeping in bed b and Supervisor A stated that was not Resident #603 but Resident #606. He stated he resides next door as their rooms connect via the bathroom and it's possible, he entered through the bathroom. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure dignity and privacy for five residents (#9, #24, #27, #35, #37) of 18 residents reviewed for dignity and privacy, resulting in feelings of being dismissed, forgotten and embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed complete assessments to determine the need for bed rails, monitor residents' continued use of bed rails, obtain physicians' orders, and implement care plans for 4 residents (#8, #14, #19, #43) and obtain consent prior to use for Resident #14, for 4 of 5 residents reviewed for entrapment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication labeling, storage and discard of medications in 4 of 4 medication carts reviewed, resulting in a lack of dating of multi-dose medications with specified time frames for use after opening.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition and 2) Maintain a correct thawing procedure for hamburger. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. Review of the facility Food Receiving and Storage policy dated 1/1/2022, revealed food items open and partly used need opened on and use by dates. On 4/1/25 at 8:00 a.m., a kitchen walk through was done accompanied by [NAME] C. The following concerns were identified during the walk through: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that fans were clean for Resident #41 and Resident #54 and oxygen tubing was stored appropriately for Resident #42. Findings Include: Resident #41: Review of the Face Sheet, MDS dated [DATE], nurses and social service notes dated 1/25 through 4/1/25 through, and care plans revealed Resident #41 was [AGE] years old, alert, admitted to the facility on [DATE], and required assistance with ADL's. The resident's diagnosis included, history of Guillain-Barre Syndrome, anemia, pulmonary embolism, diarrhea, encephalopathy, muscle weakness, depression, and anxiety. Observation done on 4/1/25 at approximately 9:45 a.m., revealed Resident #41's black fan on high blowing directly on him with an extensive amount of dust blowing on the front and back cover. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update and/or revise individualized, person-centered care plans to reflect changing care needs for 6 residents (#8, #14, #19, #28, #47, and #60) of 24 residents reviewed for care plans. Findings Include, Resident #28: Accidents On 4/01/2025 at 9:41 AM, Resident #28 was observed in the day room, sitting in a chair. The resident was awake and talkative, but confused. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #28 was admitted to the facility on [DATE] with diagnoses: Dementia, history of a stroke, hypertension, chronic pain, peripheral vascular disease, atrial fibrillation, weakness and unsteadiness on feet. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate weights were obtained for 2 residents (#35 and #47) of 6 residents monitored for food or nutrition, resulting in Resident #35 and Resident #47 having inaccurate weights documented in the medical record. Findings Include: Resident #35: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, anxiety, history of intestinal cancer, and heart disease. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 3/15 and the resident needed some assist with all care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure clean and dry storage of respiratory equipment for three residents (#25, #44, #54) of three residents reviewed for respiratory needs, resulting in unsanitary storage of respiratory equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately monitor antibiotic use and update the antibiotic line listing for one resident (#2) of 17 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Ensure consent for antipsychotic medications prior to administration for 1 resident (Resident #14) and 2) Ensure supporting documentation for use of Ativan for 1 resident (Resident #9) of 3 residents reviewed for antipsychotic medications (including anxiety medications), resulting in antipsychotic medications without appropriate consent and the use of Ativan daily at HS (night time).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an adequate amount and choice of evening snacks for a Confidential Group of residents reviewed, resulting in not getting snacks, enough snacks, feeling left out for a choice of snacks and an overall feeling of frustration.

Inspectors wroteThis citation pertains to intake #MI00147776 Based on interview and record review the facility failed to provide activities of daily living (ADL) care for one dependent resident (R2) of four residents reviewed for ADL care, resulting in poor skin conditions and lack of assistance with bed mobility and peri-care.

Inspectors wroteThis citation pertains to intakes #MI00147776 and #MI00149234. Based on interview and record review the facility failed to ensure that physician ordered medications were available for one resident (R1) and administered timely for one resident after admission (R2) of four residents reviewed for medication availability and timely medication administration, resulting in medications not being available and one resident not receiving their physician ordered medications timely.

Inspectors wroteThis Citation pertains to Intake Numbers MI00146717 and MI00147164. Based on observation, interview and record review, the facility failed to maintain a clean, safe and homelike environment on the Central Unit with an exit door latched shut, foul odors, windows not secure, disrepair of furniture, and on the East Wing Unit call lights were not in reach, for two of three Units/Wings reviewed for environmental concerns, resulting in a marked exit door not functional in case of an emergency, lack of resident, staff, and visitor safety and the potential for embarrassment, dissatisfaction with living conditions, frustration, and needs not being met.

Inspectors wroteThis Citation pertains to Intake Number MI00146717. Based on observation, interview and record review, the facility failed to ensure that residents' rights/dignity were maintained when concerns/grievances were not addressed and call lights were not answered timely for four residents (Resident #2, Resident #3, Resident #6 and Resident #9), of five residents reviewed for call light response and grievances, resulting in incontinence, feelings of frustration and anger, and needs not met timely.

Inspectors wroteThis Citation pertains to Intake Numbers MI00146717, MI00147164, MI00147177 and MI00147178. Past Non-Compliance (PNC) was presented by the facility during investigation of the allegations and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted. The Compliance Date was 09/26/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that Resident #5 had an adequate supply of oxygen while up and using the portable oxygen, 2) Failed to ensure the proper storage of nebulizer treatment equipment, and 3) Failed to replace oxygen tubing, nasal cannula, nebulizer apparatus for three residents, (Resident #2, Resident #5 and Resident #8), of 3 residents reviewed for respiratory care, resulting in potential for exacerbation of respiratory conditions, lack of oxygen, respiratory infections and diminished health and well-being.

Inspectors wroteThis Citation pertains to Intake Number MI00146646. Based on observation, interview and record review, the facility failed to properly store medication and needles/sharps on the East Wing Unit, of three units reviewed for safe environment, resulting in the potential for medication ingestion, diversion of medication and needles, and injury. Findings Include: On 9/19/24 at 10:06 AM, an observation was made of the nurses' station. There were no staff in the area. Residents were in the vicinity and nearby in the common area. The Nurses' Station had a counter that was accessible from the hall and wheelchair accessible in height. An observation was made of a bag of multiple antibiotic IV (intravenous) medication on the counter of the Nurses' Station. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to abide by one resident's (Resident #3) assessed level of assistance during incontinence care, resulting in Resident #3 rolling off of her bed and onto the floor during care and sustaining a preventable femur fracture that required surgical intervention. This citation was cited at Past Non-Compliance with a Compliance Date of 11/06/2023. Findings Include: Resident #3: On 4/29/2024 at 12:15 PM, an interview was conducted with Resident #3 regarding her stay at the facility. She reported while she recently has shown improvements, she had a fall in October 2023 when she rolled out of bed during a brief change and broke her leg. Resident #3 reported she required surgical intervention and screws in her leg from the ordeal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow policies and procedures for medication labeling and medication storage in 2 of 2 medication carts involving 14 residents (#3, #4, #6, #9, #13, #14, #22, #24, #32, #33, #39, #40, #44) medications and 1 of 1 medication rooms reviewed, resulting in opened and undated multi-dose medications, and the likelihood for altered medication efficiency.

Inspectors wroteBased on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 45 residents who consume meals from the kitchen. Findings Include: On 4/29/2024 at 9:35 AM, a tour of the kitchen was completed in the presence of Regional Dietitian L. The following expired/outdated times were found: Dry Storage Room: - 5- Minnehaha Mills Sugar Free Raspberry Gelatin packets expired 3/16/2023 - 6- Hard shell tacos in Ziploc bag, expired 3/20/24 - 5lb (pound) bag of Corn Muffin mix, expired on 12/15/2023. [...]

Inspectors wroteThis citation pertains to Intake Numbers MI00141996 and MI00143446. Based on observation, interview and record review, the facility failed to have call lights within reach or respond to in a timely manner for three residents (Resident #6, Resident #15, Resident #200) and one resident (Resident #100) being left exposed, in a review of 12 residents reviewed for dignity, resulting in residents verbalizing complaints, frustration, and likelihood for mental anguish.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the standards of practice for administration of oral Coumadin anti-coagulant and intravenous Vancomycin antibiotic medications for two residents (Resident #100, Resident #200), resulting in an excessive dose of Coumadin anti-coagulant and intravenous Vancomycin antibiotic medications therapy with the likelihood for prolonged illness and/or hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure timely completion and assessment of diagnostic/laboratory testing as well as comprehensive assessment, monitoring, and treatment following a change in condition for two residents (Resident #49, and Resident #100) reviewed, resulting in a lack of laboratory monitoring of medications for Resident #100 and Resident #49 experiencing a change in condition, a lack of comprehensive assessment, laboratory testing/results, and resident involvement in care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions timely to prevent an Unstageable (full-thickness pressure injury in which base is covered by eschar and/or slough) Coccyx Pressure Ulcer for one resident (Resident #6), resulting in a new unstageable pressure ulcer with the likelihood of further skin complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to timely assess, investigate, implement appropriate interventions, and notify practitioners and the dietitian of significant weight loss for one resident (Resident #13) of one resident reviewed for excessive weight loss, resulting in a significant weight loss of 32.3 pounds (12.52%) with delayed facility assessment and intervention for Resident #13. Findings Include: Resident #13: During initial tour, Resident #13 was observed in the dining room perusing a magazine. The resident was asked about her weight loss in January 2024, and stated she had to lose some weight as she is a basketball player. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to assess and monitor Percutaneous Inserted Central Catheter (PICC/a central line placed into a vein in the upper arm guided into a large vein above the heart) per standards of practice and failed to notify the physician of an inward migration of the PICC for two residents (R#39, 200), resulting in a complication of a 3.5 centimeter (CM) inward migration going unassessed, missed dressing changes, flushes, end cap changes with the likelihood of further complications such as further inward or outward migration, swelling, site infection going unassessed and/or unnoticed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one resident (Resident #100) was free of an unnecessary dose of Coumadin anti-coagulation with elevated laboratory Protime (PT) and International Normalized Ratio (INR) levels, resulting in the likelihood for excessive bleeding and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5% when 7 late administrations of medications were observed and 2 medication errors from a total of 30 opportunities for two residents (Resident #100, Resident #200) of 5 residents reviewed. This deficient practice resulted in a medication error rate of 30% and the likelihood for the risk of adverse medication effects and decreased medication efficacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent significant medication errors for two residents (Residents #100, Resident #200) of five residents reviewed for medication errors, when a nurse administered an anticoagulant (Blood thinner) with an elevated International Normalization Ratio (INR) to Resident #100, and another nurse administered the wrong strength of Vancomycin antibiotic medication with an elevated Vancomycin laboratory level, resulting in the likelihood for prolonged illness and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance and accurate data collection/documentation/analysis including potential infections, pneumococcal vaccination tracking, and call-in/illness tracking for contracted staff resulting in lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis, and the likelihood for spread of microorganisms and illness to all 45 facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that informed consents were obtained for non-psychotropic medications used to treat mood and behavior disorders and/or hypnotic medications for seven residents (#11, #29, #31, #37, #40, #41, #100), resulting in residents receiving medications with the lack of consents for the use and potential for unnecessary and undesired medication use.