Medilodge of Gaylord

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for all 70 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure correct implementation of transmission-based precautions (TBP) for one Resident (#87) of one resident reviewed for TBP and to ensure infection prevention and control policies were reviewed on an annual basis with the potential to affect all 70 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate and timely delivery of medications for four Residents (R13, R28, R29, and R80) of six residents reviewed for medication administration with 5 errors out of 26 opportunities resulting in a medication error rate of 19%.

Inspectors wroteBased on observation, interview and record review, the facility failed to label opened multi-use medications, removed expired medications and ensure storage of medications according to professional standards of practice in two of two medication carts reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an order, care plan interventions and goals for one Resident (Resident #58) of two residents reviewed for indwelling catheters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders for the administration of supplemental oxygen, completion of respiratory assessments with respiratory treatments, appropriate cleaning and storage of respiratory equipment, and supervision during the administration of respiratory treatments for three Residents (R36, R80, R13) of five residents reviewed for respiratory care services.

Inspectors wroteBased on interview, and record review, the facility failed to explain and obtain an acknowledgement of understanding for a binding arbitration agreement for one Resident (R10) of three Residents reviewed for proper execution of the facility's binding arbitration agreement.

Inspectors wroteBased on interview and record review the facility failed to ensure communication/documentation occurred for coordination of care for hospice services provided for one Resident (R47) of one Resident reviewed for hospice services.

Inspectors wroteBased on interview and record review, the facility failed to ensure eligible residents were offered influenza and pneumococcal vaccines as recommended by the Centers for Disease Control and Prevention (CDC) for 2 residents (#12 and #87) of 5 residents reviewed for vaccination status. Findings Include:Resident #12 (R12)Review of R12's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/22/26 with diagnoses including cerebral infarction (stroke), moderate persistent asthma, dementia, and dysphagia (difficulty swallowing). Review of R12's Michigan Care Improvement Registry (MCIR [a database that documents immunizations administered to individuals in Michigan]) revealed the pneumococcal vaccination was, DUE NOW.Further review of R12's EMR revealed she was not offered a pneumococcal immunization. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure eligible residents were offered a COVID-19 immunization as recommended by the Centers for Disease Control and Prevention (CDC) for 2 residents (#12 and #87) of 5 residents reviewed for vaccination status. Findings Include:Resident #12 (R12)Review of R12's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/22/26 with diagnoses including cerebral infarction (stroke), moderate persistent asthma, dementia, and dysphagia (difficulty swallowing). Review of R12's Michigan Care Improvement Registry (MCIR [a database that documents immunizations administered to individuals in Michigan]) revealed COVID-19 2025-26 was, DUE NOW.Further review of R12's EMR revealed she was not offered a COVID-19 immunization. [...]

Inspectors wroteThis citation pertains to Intake 2727226. Based on observation, interview, and record review, the facility failed to act upon a physician's order for one Resident (#2) out of three residents reviewed for quality of care. This deficient practice caused delayed medical treatment for Resident #2 resulting in the need for transfer to an emergency department (ED) due to septic shock (a life-threatening condition which occurs when blood pressure drops to a dangerously low level after an infection).

Inspectors wroteThis citation pertains to Intake 2741948. Based on interview and record review, the facility failed to ensure a medication was administered in the prescribed form for one Resident (#1) of three residents reviewed for quality of care.

Inspectors wroteThis citation pertains to Intake 2741948. Based on interview and record review, the facility failed to ensure prescribed medications were readily available for one Resident (#1) of three residents reviewed for pharmacy services.

Inspectors wroteThis citation pertains to intake 1234972Based on interview and record review, the facility failed to protect two Residents (#1 and #2) of four resident reviewed for right to be free from sexual abuse. This deficient practice resulted in psychosocial harm including feelings of embarrassment, devastation, anxiety, feelings of being violated, and trauma based on a reasonable person standard.

Inspectors wroteBased on observation and interview, the facility failed to properly store and dispose of expired medications, and log refrigerator temperatures for immunization and insulin medications for one of one medication room and three of three medication carts reviewed for medication storage.

Inspectors wroteBased on interview and record review, the facility failed to implement an infection prevention and control program (IPCP) to prevent, recognize, and control infections, and failed to update infection control policies annually. This deficient practice resulted in the potential spread of infectious organisms and disease to all 82 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified Infection Preventionist was employed at least part-time in the facility and was present to properly assess, implement, and manage the Infection Prevention and Control Program (IPCP). This deficient practice resulted in the potential for the spread of infection and communicable diseases to all 82 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide written transfer notifications to the resident/resident's representative and the Office of the State Long-Term care Ombudsman including reason, effective dates, and the location to which the resident was being transferred for four Residents (#5, #16, #33, #43) of seven residents reviewed for transfers out of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure four Residents (#5, #16, #33, and #43) of eight residents reviewed for hospitalization were provided written notice of bed hold when the residents were transferred to the hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain personal privacy of medical information for one hallway of four hallways reviewed. This deficient practice resulted in Residents privacy being breached.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate care was provided for Moisture Associated Skin Damage (MASD) according to professional standards of practice for one Resident (#47) of one resident reviewed for MASD. This deficient practice resulted in the potential for delayed wound healing, worsening of condition and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer supplemental oxygen according to physician orders, change and date respiratory equipment, appropriately store respiratory equipment, and clarify parameters for administration of supplemental oxygen for three Residents (#330, #331, and #43) of seven residents reviewed for respiratory care services.

Inspectors wroteBased on interview and record review, the facility failed to timely destroy discontinued scheduled II medication and dispensed medication without a physician order for one Resident (#58) and failed to initiate a stop date on an as needed antianxiety medication for one Resident (#279) of eighteen residents reviewed for pharmacy services.

Inspectors wroteBased on interview and record review, the facility failed to: 1) ensure non-pharmacological interventions attempted and failed prior to the administration of as needed (prn) anxiolytic medication were documented; 2) ensure appropriate indication for use for an antipsychotic medication; and, 3) ensure consideration of a gradual dose reduction (GDR) of an anti-depressant medication, affecting three Residents (#68, #179, & #20) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate record of wounds for one Resident (#15) of two residents reviewed for wound documentation, resulting in the inaccurate reflection of the resident's condition and the potential for communication of inaccurate medical information to healthcare providers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure daily posting of nurse staffing information, resulting in the inability of residents, resident's representatives and visitors to determine the number of staff available to provide resident care and had the potential to affect all 82 residents in the facility.

Inspectors wroteThis citation relates to Intake #MI00145643. Based on observation, interview, and record review, the facility failed to ensure comprehensive and timely cardiac and respiratory assessments per professional standards of practice for two residents (R1, R2) of two residents reviewed with cardiac and respiratory conditions.

Inspectors wroteBased on interview and record review, the facility failed to provide written transfer notifications to the resident and/or resident's representatives including reason, effective dates, and the location to which the resident was being transferred for six Residents (R10, R11, R36, R39, R41, R65) of six residents reviewed for transfers out of the facility. This deficient practice resulted in the potential for residents and/or resident's representatives to be uninformed, as well as a potential for inappropriate discharge/transfers.

Inspectors wroteBased on interview and record review, the facility failed to ensure six residents (R10, R11, R36, R39, R41, R65) of six residents reviewed for hospital discharges, were provided written notification of the bed hold policy upon transfer. This deficient practice resulted in the potential for the residents and/or their responsible parties to be uniformed of the bed hold policy and their rights following a transfer to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete treatments as ordered by the physician, adhere to physician's orders for frequency of dressing changes, and maintain infection control practices to promote the healing of pressure injuries for one Resident (#65) of two residents reviewed for pressure injuries. This deficient practice had the potential to result in infections, worsening of existing pressure injuries, and the development of additional wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary drainage system was maintained in an aseptic manner for one Resident (#65) of 3 residents reviewed for catheters. This deficient practice resulted in the potential spread of infectious organisms, and the potential for R#65 to experience worsening of an existing urinary tract infection. Resident #65 (R65) was admitted to the facility on [DATE] with diagnoses that included but were not limited to: urinary tract infection (UTI), muscle weakness, need for assistance with personal care, lack of coordination, convulsions, unspecified lack of expected normal physiological development in childhood, subarachnoid hemorrhage (bleeding in the brain), and cerebral palsy. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure pharmacist irregularities reported in the monthly medication review were addressed timely in the medical record by the physician for two Residents (R50 & R55) of five residents reviewed for drug regimen reviews. This deficient practice resulted in the potential for unnecessary medications, drug interactions and undesirable medication side effects.

Inspectors wroteBased on interview and record review, the facility failed to adhere to 14-day PRN psychotropic and antipsychotic prescription durations and ensure gradual dose reductions were attempted, unless contraindicated, for three Residents (R50, R55, and R27) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for the administration of unnecessary medications and risk of medication adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Hospice Plan of Care was retained in the facility for one Resident (R35) of one resident reviewed for Hospice care. This deficient practice resulted in the potential for lack of continuity of care when the facility was not updated on the care and services planned and provided to R35.