Medilodge of Kalamazoo

Inspectors wroteThis citation pertains to intake #3005153 and #3005264Based on interview and record review the facility failed to ensure a safe discharge for 1 (Resident #103) of 2 residents reviewed for transfer and discharge, when on 5/4/26 at approximately 11:45 pm, Resident #103 was not allowed back into the building upon her return from an evaluation and subsequent diagnosis of a UTI (urinary tract infection) at a local acute care emergency department. This deficient practice resulted in Resident #103 being without food, shelter, medications, or resources for safety; further resulting in Resident #103 experiencing feelings of fear, anger, and mental anguish.

Inspectors wroteThis citation pertains to intake #3030592Based on observation, interview, and record review the facility failed to ensure residents were assessed to be appropriate for self-administration of medications for 1 (Resident #104) of 1 resident reviewed for medication administration resulting in medications being left unsecured at resident's bedside, residents self-administering medications without staff assessment, and the potential for negative outcomes from taking/instilling too much or too little medications.

Inspectors wroteThis citation pertains to intake #3030592Based on observation, interview, and record review the facility failed to maintain professional standards of nursing practice for 1 (Resident #104) of 4 resident reviewed for professional nursing standards resulting in ordered medications not being obtained from a pharmacy, no monitoring of home medication use, medications left unsecured at resident's bedside, and the potential for negative outcomes from taking/instilling too much or too little medications.

Inspectors wroteThis citation pertains to intake #3030592Based on observation, interview and record review, the facility failed to ensure nursing staff were adequately trained and evaluated for competencies specifically related to the management of an insulin pump for 1 (Resident #104) of 1 reviewed for the management of an insulin pump. This deficient practice had the potential to result in ineffective medication therapy, complications, and adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide positioning for the prevention of pressure wounds in 1 (R1) of 4 residents reviewed for pressure wounds resulting in the development of a pressure wound.

Inspectors wroteBased on interview and record review the facility failed to develop policy and procedure to include current standards of practice in regard to pneumococcal (pneumonia) immunizations for 2 (Residents #1 and 10) of 5 residents reviewed for immunizations and the potential for eligible residents to not be offered the PCV21 (Pneumococcal 21-valent Conjugate Vaccine), with the potential of increasing the risk of acquiring, transmitting, or experiencing complications from pneumonia.

Inspectors wroteThis citation pertains to intake 2590016. Based on interview and record review the facility failed to ensure the designated resident representative was notified of changes for 1 (Resident #501) of 3 residents reviewed for notification of changes resulting in a resident representative being unaware of x-ray results and falls, a resident representative experienced the feeling of uncertainty of how their family member was being cared for at the facility, and the potential for resident representatives to be unable to make timely care decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to support meaningful involvement in activities of choice, for 1 (Resident #14) of 12 residents reviewed for meaningful activities resulting in the potential for feelings of boredom, loneliness, and unmet psychosocial needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision and ambulation device to prevent falls and fall with injury in 1 (R31) of 4 residents reviewed for accidents resulting in injury and the potential of further falls with injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1.) maintain proper infection control practices while utilizing resident shared equipment (a glucometer- a machine that uses a drop of blood to analyze the level of glucose (sugar) in a person's blood stream) during medication administration for 1 (Resident #88) of 5 residents reviewed for medication administration and 2.) ensure appropriate use of Enhanced Barrier Precautions (EBP) in 1 of 12 residents (Resident #1 (R1) reviewed for infection control, resulting in the potential for the spread of infection, cross contamination and disease transmission.

Inspectors wroteThis citation pertains in intake MI00152648 Based on observation, interview, and record review, the facility failed to provide assistance with toileting for 1 (Resident #103) of 5 residents reviewed for activities of daily living (ADL) care resulting in the potential for avoidable negative physical outcomes for resident's who are dependent on staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to provide timely notification to a representative of the Office of the State Long-Term Care Ombudsman for emergency transfer and written notice of transfer for 2 of 2 residents (Resident #2 and #9) reviewed for notification of transfers for hospitalization, resulting in the potential for residents being inappropriately discharged , residents left without an advocate to inform them of their rights, and for the Office of the State Long-Term Care Ombudsman to be unaware of the facilities practices related to transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 of 2 residents (Resident #2 and #9) reviewed for bed hold, resulting in possible unanticipated expense or the loss of desired room placement in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents with a history of trauma received trauma informed care for 1 (Resident #4) of 12 sampled residents resulting in the potential for exposure to trauma triggers and re-traumatization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were maintained for 2 (Resident #38 and Resident #191) of 2 residents reviewed for catheter care, resulting in the catheter bag and/or tubing being left on the floor and an increased risk of cross contamination and infection.

Inspectors wroteThis citation pertains to MI00143151. Based on interview and record review, the facility failed to provide an environment free from physical abuse from staff to one resident (R105) of six residents reviewed for abuse, resulting in physical abuse, and the potential for continued fear, anxiety, and psychosocial harm.

Inspectors wroteReview of The Needs of Older People with Dementia in Residential Care, Woods & [NAME] (2006), published in the International Journal of Geriatric Psychiatry revealed Determining which activities have high degree of meaningfulness can aide recreation staff in creating programs more likely to promote health and wellness for persons with dementia. Review of Activity Involvement and Quality of Life of People at Different Stages of Dementia in Long Term Care Facilities, [NAME] & Twist (2015), published in Aging Mental Health, revealed Despite a Resident's cognitive status, their activity involvement was significantly related to better scores on care relationships, positive affect, restless tense behavior, social relations and having something to do. [...]

Inspectors wroteThis citation pertains to Intake # MI00135264. Based on interview and record review, the facility failed to respond timely to a request for medical records in 1 resident (Resident #38) of 1 resident reviewed for medical record requests, resulting in delayed access to a resident's medical records and dissatisfaction with the services provided.

Inspectors wroteThis citation pertains to Intake # MI00135264. Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the reason for a transfer to the hospital in 3 of 5 residents (Resident #38, #6, & #23) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to not be fully informed of the reason for a hospital transfer and their rights in regard to an appeal hearing.

Inspectors wroteThis citation pertains to Intake # MI00135264. Based on interview and record review, the facility failed to provide written notification of the bed hold policy upon transfer to the hospital in 3 of 5 residents (Resident #38, #6, & #23) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to be unaware of their rights in regard to facility bed holds.

Inspectors wroteThis citation pertains to Intake # MI00130822. Based on observation, interview, and record review the facility failed to develop and implement person centered care plans for 3 of 12 residents (Resident #15, Resident #27 and Resident #21) reviewed for care plans, resulting in the potential for staff to not know how to care for resident conditions or follow resident care interventions.

Inspectors wroteThis citation pertains to Intake # MI00130822. Based on observation, interview, and record review the facility failed to prevent the development of an avoidable pressure ulcer for 1 of 12 sampled residents (Resident #15) resulting in the development of a pressure ulcer and the potential for delayed wound healing, pain, infection and overall deterioration in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision according to the standards of care and consistently implement adequate and effective interventions to prevent further falls in 1 of 7 residents (Resident #22) reviewed for safety, resulting in the potential for wandering into other residents' rooms, accidents/hazards with the potential for injury and/or resident to resident altercations.