Medilodge of Lansing

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to clean and maintain food service equipment affecting 75 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant affecting 75 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician medication and wound treatment orders in accordance with professional standards of practice, implement care plans, and provide resident care choices for one resident (R70) of 18 reviewed for quality of care, resulting in wound decline, uncontrolled pain and overall feelings of anger and frustration. Review of the Face Sheet, dated 12/3/25, reflected R70 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included paraplegia (paralyzed below waist), multiple pressure ulcers up to stage IV(full thickness tissue/muscle loss), hypertension, pain, anxiety and depression. Review of the Progress Note, dated 11/11/25, reflected, Therapy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess and ensure adequate pain management for one of 18 reviewed for pain (Resident #70), resulting in untreated and unnecessary pain for R70. Review of the Face Sheet, dated 12/3/25, reflected R70 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included paraplegia (paralyzed below waist), multiple pressure ulcers up to stage IV(full thickness tissue/muscle loss), hypertension, pain, anxiety and depression. Review of the Progress Note, dated 11/11/25, reflected, Therapy: unable walk or do transfer she[R70] is dependent on that task max for lower dressing sock and shoes toilet hygiene is max mod assist for upper body dressing bed mobility set up for eating and personal care. Nursing: wound care pain management, medication management, labs super pubic cath. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to honor dietary preferences for one (Resident #12) out of 3 reviewed for nutrition.

Inspectors wroteBased on observation and interview, the facility failed to update the daily staff posting with a current facility census of 75 residents.

Inspectors wroteThis citation pertains to Intake 2656668. Based on observation, interview and record review, the facility failed to report an allegation of abuse to the State Agency for one (R6) of three reviewed.

Inspectors wroteThis citation pertains to Intake 2656668. Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of abuse for one (R6) of three reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that controlled medication was administered and documented according to professional practice for one medication cart (to include six residents #7, #8, #9,#10, #11, and #12) out of five medication carts reviewed. Findings Included:Resident #7 (R7)Review of the medical record revealed R7 was admitted to the facility 08/18/2022 with diagnoses that included Parkinsons Disease, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease (disease caused by plaque buildup in arterial walls), hyperlipidemia (high fat content in blood), emphysema (chronic lung disease with destruction and enlargement of the air sacs in the lungs), hypertension, orthostatic hypotension (low blood pressure on rising), anxiety, constipation, polyneuropathy (peripheral nerve damage), and chronic pain. [...]

Inspectors wroteThis Citation Pertains to Intake # 2567245Based on interview and record the facility failed to ensure adequate care, follow up and documentation were in place regarding Advanced Directives, resident alleging fear of certain family members, and failure to assess, monitor and investigate allegations of unwanted visitors giving a resident medication that was not prescribed by facility physician and provided by facility pharmacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents who consume food from the kitchen with a current facility census of 62 residents.

Inspectors wroteBased on observation and interview the facility failed to provide and maintain therapy equipment in a manner that would allow for safe and consistent operation that meets the needs of all residents. Findings Include: An interview with Physical Therapy Manager (PTM) U, at 2:50 PM on 10/1/24, found that some equipment in therapy has not been working properly for all residents. When asked what issues have been occurring, PTM U went on to state that the parallel bars are not wide enough to be used properly for our residents who are bariatric. When asked how they are used for those residents now, PTM U stated that those residents have to use the side of the parallel bars and that makes them unable to use both sides to stabilize as they walk down. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans for three (Resident #34, #57, and #62) of 16 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent an elopement and respond timely to a door alarm for one (Resident #33) of one reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of an antipsychotic medication according to provider recommendations for one (Resident #58) of five reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when two medication errors were observed from a total of 25 opportunities for two residents (Resident #22 and Resident #36) of four reviewed resulting in a medication error rate of 8%.

Inspectors wroteThis citation pertains to intake: MI00143250, MI00143278 Based on observation, interview, and record review the facility failed to insure that one resident #1 (R1) was free from significant medications errors out of four residents reviewed for significant medication errors resulting in the potential for adverse physical reactions/outcomes to residents. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, date mark potential hazardous foods, and maintain the ice machine, resulting in the potential biological contamination of food products, affecting all residents that consume food from the kitchen.

Inspectors wroteResident #64 (R64) Review of the medical record revealed R64 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses that included diabetes, lymphedema, major depressive disorder, acute kidney failure, hypertension, pain, and cellulitis. Review of the Nursing admission Evaluation dated 8/26/22 revealed R64 had a right heel pressure ulcer. Review of the Skin & Wound Evaluation dated 8/30/22 revealed R64's wound was a diabetic ulcer. Review of the Physician's Progress Note dated 9/22/22 revealed R64 had a right heel diabetic wound. Review of the Physician's Progress Note dated 9/26/22 revealed R64 had a diabetic foot ulcer. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/22 revealed R64 had an unstageable pressure ulcer. Review of the discharge MDS with an ARD of 9/27/22 revealed R64 had an unstageable pressure ulcer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to revise care plans for four (Resident #17, #26, #35 and #38) of 16 reviewed for Care Plans, resulting in inaccurate care plans and the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure current Letters of Guardianship were accessible in the medical record for one (Resident #43) of one reviewed for advance directives, resulting in the potential for medical and treatment decisions to be made by an inactive Guardian.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient notice of medicare non-coverage for one (Resident #3) of three reviewed, resulting in Resident #3 not having sufficient time to allow for an appeal

Inspectors wroteBased on interview and record review the facility failed to report allegations of abuse for one resident (#61) of 3 residents reviewed abuse resulting in allegations of abuse not being reported to the State Agency and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 05/02/2023 with diagnoses that included supraventricular tachycardia, stage 4 kidney disease, atrial fibrillation, type 2 diabetes, ischemic heart disease, anemia (low red blood cell count), morbid obesity, adjustment disorder with anxiety and depression, gastro-esophageal reflux, hypothyroidism (low thyroid hormone), chronic congestive heart failure (CHF), major depression, hyperlipidemia (high fat in blood), pain of the right hip, and hypertension. [...]

Inspectors wroteThis citation pertains to Intake MI00138169 Based on interview and record review, the facility failed to shower/bathe one resident (Resident #64) of one reviewed, resulting in the potential for uncleanliness and embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) ensure coordination of care with an outside provider for one (Resident #28) of 15 reviewed for quality of care; and 2) identify, assess and monitor a wound for one (Resident #17) of 15 reviewed for quality of care, resulting in the potential for lack of care coordination, worsening wounds and delayed wound healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure tube feeding was provided according to physician's orders for one (Resident #43) of one reviewed for tube feeding, resulting in the administration of a tube feeding formula that was not ordered and the potential for weight loss and nutritional deficits.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an additional LaryTube (silicone tube designed to maintain an airway of a laryngectomy) was in the room for one (Resident #28) of one reviewed for respiratory care, resulting in the potential for delay in obtaining necessary supplies in an emergency situation.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable practice for maintaining controlled medication for two out of three medication carts resulting in the potential for controlled medication diversion. Finding Included: During observation of D hall 1st medication cart on 07/19/2023 at 11:20 a.m. it was observed that the facility Narcotic Shift Count record was last signed by two nurses on 07/18/2023 at 07:00 p.m. The off going nurse section was signed for the date of 7/19/2023 at 06:30 a.m. The on coming nurse section for the date of 07/19/2023 at 06:30 a.m. was blank. During this observation Licensed Practical Nurse (LPN) E signed the on coming nurse section for the date of 07/19/2023 at 06:30 a.m. During observation of D hall 2nd medication cart on 07/19/2023 at 11:32 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician ordered parameters upon the administration of blood pressure medications for one (Resident #56) of five residents reviewed, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide clinical justification for the use of psychotropic for two residents (#26,#38) of five residents reviewed for unnecessary medication, resulting in the potential for unnecessary medication. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when two medication errors were observed from a total of 25 opportunities for one resident (Resident #49) of six residents reviewed for medication administration, resulting in a medication error rate of 8% and the potential for adverse reactions/side effects.

Inspectors wroteBased on interview and record review, the facility failed to track and provide the pneumococcal vaccination timely for one (Resident # 13) of five residents reviewed for immunizations, resulting in the potential for incomplete vaccination, and the potential for serious illness and complications from pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to provide a requested COVID-19 bivalent booster in a timely manner for one (Resident #7) of five residents reviewed for immunizations, resulting in an increased risk for infection, and the potential spread of COVID-19 infection to other residents, staff, and visitors.