Medilodge of Leelanau

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications properly and maintain a clean medication cart for one of two medication carts and two Residents (R24 and R48) of six residents reviewed for medication storage.

Inspectors wroteBased on interview and record review, the facility failed to ensure a recapitulation of stay and the Long-Term Care Ombudsman were notified of a resident's discharge from the facility for one Residents (#74) of two residents reviewed for discharge practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform Activity of Daily Living (ADL) care (finger and toenail trimming services) for one resident (R12) of one resident reviewed for ADL care.

Inspectors wroteBased on interview and record review, the facility failed to observe the consumption of medication for one Resident (R6) of one resident reviewed for quality of care. This deficient practice resulted in R6 consuming acetic acid with medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative therapy services per the resident care plan for one Resident (R63) of one resident reviewed for restorative therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate and standards of practice of medication administration for two Residents (R47 and R59) of four residents reviewed for medication administration with 4 errors out of 29 opportunities resulting in a medication error rate of 14%.

Inspectors wroteThis citation pertains to intake number 2711126Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident. This deficient practice resulted in Resident 1 (R1) inappropriately touching Resident 2 (R2) causing R2 to feel mental trauma based on the reasonable person concept.

Inspectors wroteThis deficiency pertains to Intake MI00147043 Based on observation, interview, and record review, the facility failed to maintain sufficient staff for four (Resident #8, #37, #41, and #63) of seventeen residents reviewed for staffing.

Inspectors wroteBased on interview and record review, the facility failed to conduct and document an annual facility wide assessment resulting in the potential for inadequate resources to meet the needs and care for all 68 facility residents. On 12/9/24 during the entrance conference at 11:50 AM the Nursing Home Administrator (NHA) was asked for a copy of the Facility Assessment. The NHA provided a Facility Assessment Tool for 7/2023 through 6/2024. The NHA was asked if there were any updates to the facility assessment to meet the requirement of being reviewed and updated annually. During a follow-up interview on 12/10/24 at 3:20 PM, the NHA stated all files provided were the most current. Review of the Facility Assessment tool section titled Average Daily Census Analysis indicated the patient population had an average of 63 which did not reflect the current resident population.

Inspectors wroteBased on interview and record review, the facility failed to update infection control policies annually. This deficient practice has the potential to affect all 68 residents regarding infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly secured, physician's orders for self-administration of medications were clarified, and residents were adequately assessed for self-administration of medications for two Residents (R14 and R46) of three residents reviewed for self-administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure written bed-hold information was provided to two Residents/Representatives (#22 & #57) of three residents reviewed for written notice of bed hold.

Inspectors wroteThis deficiency pertains to MI00147043 Based on interview and record review, the facility failed to provide necessary showers during preferred times for two Residents (#6 and #22) of eighteen residents reviewed for ADL's (Activities of Daily Living).

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent falls with further injury for one Resident (#3) of three residents reviewed for falls. This deficient practice resulted in the risk for further falls with injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate catheter care and maintenance for one Resident (#22) of one resident reviewed for catheter care.

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were addressed by the physician and maintained in the clinical record for one Resident (#9) of five residents reviewed for MRRs.

Inspectors wroteBased on interview and record review, the facility failed to offer snacks in the evening for three Residents (#6, #22, and #31) of eighteen residents reviewed for evening snacks.

Inspectors wroteBased on interview and record review, the facility failed to administer a COVID-19 vaccination as requested by one Resident (R14) of five residents reviewed for immunizations.

Inspectors wroteThis citation pertains to intake: MI00146857 Based on interview and record review, the facility failed to report an allegation of staff to resident sexual abuse to the State Agency (SA) for one Resident (R900) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake: MI00146857 Based on interview and record review, the facility failed to conduct a thorough investigation for a staff to resident sexual abuse allegation for one Residents (R900) of three residents reviewed for abuse.

Inspectors wroteThis Citation pertains to Intakes: MI00140257 and MI00140613 Based on observation, interview, and record review, the facility failed to provide adequate staff to meet the needs of the residents as evidenced by: - lack of routinely passing water, - long wait times for assistance with reported bladder accidents and missing of scheduled activities, - lack of routinely offering bedtime snacks. This deficient practice resulted in feelings of frustration and insignificance on the part of 11 out of 13 residents who attended the confidential group meeting.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fresh water was consistently offered and provided for 7 residents (R4, R8, R21, R31, R34, R51, R53) and 5 of 13 residents attending the confidential group meeting. This deficient practice resulted in resident dissatisfaction, and the potential for feelings of thirst and dehydration.

Inspectors wroteBased on interview and record review the facility failed to follow their grievance process to act on resident concerns brought up in Resident Council. This deficient practice produced frustration and feelings of insignificance on the part of 10 out of 13 residents who attended the confidential group meeting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen services per standards of practice and per physician orders for four residents (Resident #9, Resident #10, Resident #22, and Resident # 34) of four residents reviewed for oxygen services. This deficient practice resulted in the potential for the development of respiratory complications, including infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to securely store medication, securely deliver medications during medication pass, and maintain clean and sanitary medication carts for two of two medication carts reviewed for medication storage. This deficient practice had the potential for medications to be misappropriated, medication loss, and contamination.

Inspectors wroteBased on interview, and record review the facility failed to provide snacks in the evening for seven out of 13 Confidential Residents (C1, C2, C3, C5, C7, C8, and C13) interviewed in the confidential group meeting. This deficient practice resulted in residents verbalizing disappointment and dissatisfaction as well as the potential for hunger and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bathing/showers per individual resident needs and preferences for one resident (Resident #10) of 18 residents reviewed for Activities of Daily Living (ADL) care, resulting in psychosocial sadness, and the potential of poor hygiene, skin irritation, and breakdown. This citation is related to intake: MI00140257 Resident #10 (R10) According to the Minimum Data Set (MDS) dated [DATE], R10 scored 15/15 (cognitively intact) on his BIMS (Brief Interview for Mental Status), with diagnoses including Diabetes Mellitus, hypertension, and depression. These diagnoses along with impairment in both legs, required R10 to receive substantial maximum assistance from one person for turning/positioning in bed, and two-person assistance for transfers. R10 required one-person substantial maximum assistance for bathing/showers. [...]

Inspectors wroteThis citation contains 2 deficient practices. Deficient Practice #1: Based on observation, interview, and record review, the facility failed ensure the environment remained free of accident hazards and failed to assess the amount of supervision required during smoking for two Residents (R23, and R63) of two residents reviewed for smoking. This deficient practice resulted in the potential for avoidable accidents including but not limited to harm from burns, fires, or falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete and post the daily nurse staffing information at the beginning of each shift. This deficient practice resulted in the inability of residents and visitors to determine the number of staff available to provide resident care and had the potential to affect all 61 residents in the facility.