Medilodge of Marshall

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 91 residents who consume food, resulting in the increased likelihood for improper mechanical dish machine sanitization rinse water pressure, cross-contamination, and bacterial harborage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 91 residents, resulting in the increased likelihood for cross-contamination, and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain consent prior to the initiation of a mood stabilizer and anti-depressant medication and subsequent dosage increase in two (Resident #1, #63) out of five reviewed for medication review.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for one (R8) of 19 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct care conference meetings for one (R33) of 19 reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound care orders were implemented upon readmission from the hospital for one (R2) of 19 reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered medication monitoring was completed for one (R45) of five reviewed.

Inspectors wroteThis citation pertains to intake numbers 2790883 and 2790891. Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident. Findings Include:Review of the medical record reflected Resident #4 (R4) was admitted to the facility on [DATE], with diagnoses that included pseudobulbar effect (a neurological condition causing sudden uncontrollable episodes of laughing or crying), mild cognitive impairment, chronic motor or vocal tic disorder, and severe intellectual disabilities. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/26, reflected R4 was marked as rarely/never understood on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). [...]

Inspectors wroteThis citation pertains to intake number 2801450 Based on interview and record review, the facility failed to ensure appropriate urostomy care for one resident (resident #7) out of three reviewed, resulting in a hospitalization for a diagnosis of septic shock secondary to a urinary tract infection.

Inspectors wroteThis citation pertains to intake 2801450. Based on interview and record review, the facility failed to notify the resident representative of a change in condition for one (R7) of four reviewed.

Inspectors wroteThis citation pertains to intake numbers 2788433 and 2790891. Based on observations, interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings Include:Review of the medical record reflected Resident #4 (R4) was admitted to the facility on [DATE], with diagnoses that included pseudobulbar effect (a neurological condition causing sudden uncontrollable episodes of laughing or crying), mild cognitive impairment, chronic motor or vocal tic disorder, and severe intellectual disabilities. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/26, reflected R4 was marked as rarely/never understood on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). [...]

Inspectors wroteThis citation pertains to intake numbers 2790883 and 2790891 Based on observation, interview, and record review the facility failed to conduct a thorough abuse investigation for 6 (R2, R3, R4, R5, R6, R16) out of 6 residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake 2741317. Based on observation, interview and record review, the facility failed to conduct root cause analysis and develop interventions to prevent falls for one (R1) of three reviewed for falls.

Inspectors wroteThis citation pertains to intake number 3013328 Based on observation and interview, the facility failed to ensure meals were served in a manner that maintained an appetizing appearance and palatability.

Inspectors wroteThis citation pertains to intake number 3013328 Based on observation, interview, and record review the facility failed to honor resident food preferences in one (Resident #12) out of three reviewed for food preferences.

Inspectors wroteThis citation pertains to Intake 2728065. Based on observation, interview, and record review, the facility failed to administer medications as ordered for one (R2) of three reviewed.

Inspectors wroteThis citation pertains to Intake: 2644057Based on observation, interview, and record review the facility failed to prevent the development of pressure ulcers for one resident (#4) out of three residents with pressure ulcers reviewed, resulting in the development of two unstageable pressure ulcers and one stage 3 pressure ulcer. [...]

Inspectors wroteThis citation pertains to intake: 2672585Based on observations/interviews/record review, the facility failed to protect the resident's (R2's) right to be free from verbal abuse and physical abuse by a resident. Findings Included:Resident #2 (R2)Review of the medical record revealed R2 was admitted to the facility 11/19/2024 with diagnoses that included pseudobulbar effect (a neurological condition causing sudden uncontrollable episodes of laughing or crying), cognitive impairment, severe intellectual disabilities (significant limitations in mental ability), bipolar disorder, social phobia, hypertension, gastro-esophageal reflux disease, depression, dysphagia, hypothyroidism (low thyroid hormone), obesity, and conversion disorder with seizures or convulsions (a condition where psychological stress or trauma manifest as real physical symptoms affecting movement). [...]

Inspectors wroteThis citation pertains to intake: 2642660 Based on observation, interview, and record review the facility failed to ensure that Nursing staff followed professional standards for medication administration for one resident (#1) out of three residents reviewed for medication administration. Findings Included:Resident #1 (R1)Review of the medical record revealed R1 was admitted to the facility 02/19/2025 with diagnoses that included depression, thyroiditis (inflammation of the thyroid gland), gastro-esophageal reflux, osteoporosis (weak and brittle bones), dementia, hypercholesterolemia (high cholesterol), sleep apnea, insomnia, chronic pain, dysphagia, and (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, did not have a Brief Interview for Mental Status (BIMS) conducted. [...]

Inspectors wroteThis citation pertains to intake: 2642660Based on observation, interview, and record review the facility failed to prevent significant medication errors for one resident (#1) out of three residents reviewed for medication errors. Findings Included:Resident #1 (R1)Review of the medical record revealed R1 was admitted to the facility 02/19/2025 with diagnoses that included depression, thyroiditis (inflammation of the thyroid gland), gastro-esophageal reflux, osteoporosis (weak and brittle bones), dementia, hypercholesterolemia (high cholesterol), sleep apnea, insomnia, chronic pain, dysphagia, and (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, did not have a Brief Interview for Mental Status (BIMS) conducted. [...]

Inspectors wroteThis citation pertains to intake 2595312. Based on observation, interview, and record review, the facility failed to ensure an abuse allegation was reported timely to the State Agency for one (R5) of five reviewed.

Inspectors wroteThis Citation pertains to Intake #1286451Based on observation, interview, and record review, the facility failed to report allegations of abuse to the State Agency for 6 (Resident #2, #3, #5, #9, #10, #11) of 8 reviewed, resulting in allegations of abuse that were not reported to the State Agency and the potential for further allegations of abuse to go unreported.

Inspectors wroteThis Citation Pertains to Intake #1286451Based on interview and record review the facility failed to thoroughly investigate allegations of abuse for seven residents (#2, #3, #4, #5, #9, #10, and #11) of 8 reviewed for abuse.

Inspectors wroteThis Citation Pertains to Intake #1286451Based on observations/interviews/record review, the facility failed to protect the resident's (Resident #1) right to be free from verbal abuse and physical abuse by Certified Nursing Assistant (CNA) IFindings include:Review of the clinical record revealed Resident #1 (R1) was under hospice care, review of the Minimum Data Set (MDS) dated [DATE] revealed R1 scored 12 out of 15 (cognitively intact) on the Brief Interview Mental Score. On 07/16/25 at 9:45am during a bedside interview, R1 was resting in bed, when queried about his care and treatment it was reported that there were no concerns with the exclusion of an incident that occurred about a year earlier that involved a Certified Nursing Assistant (CNA). [...]

Inspectors wroteThis citation pertains to intake 1286453Based on observation, interview, and record review the facility failed to provide scheduled bathing and complete nail care for one resident (R6) of three residents reviewed for activities of daily living.

Inspectors wroteThis citation pertains to intake: MI00153167 Based on interview and record review the facility failed to provide Activities of Daily Living (toileting and incontinence care) for one dependent resident (#1) of 3 residents reviewed. Findings Included: [...]

Inspectors wroteThis citation pertains to intake: MI00153167 Based on interview and record review the facility failed to implement physician orders for the administration of pain medication for one resident (#1) of three residents reviewed. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess and monitor pressure ulcers for one resident (#7) of three residents reviewed. Findings Included: Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 02/24/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), repeated falls, enlarged prostate, pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), adjustment disorder, dyspnea (difficult or labored breathing), dementia with agitation, constipation, hypertension, obstructive sleep apnea, and atherosclerotic heart disease (damage or disease of hearts major blood vessels). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 91 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for one resident of one resident reviewed for grievances (Resident #52), resulting in anger, frustration and unresolved grievances.

Inspectors wroteBased on interview and record review the facility failed to complete accurate Minimum Data Set (MDS) assessments for one resident (#8) of 19 residents reviewed for MDS accuracy, resulting in inaccurate MDS assessments. Findings Included: Resident #8 (R8) Review of the medical record demonstrated R8 was admitted to the facility 02/23/2025 with diagnoses that included type 2 diabetes, hypertension, stage 3 kidney disease, vascular dementia, cognitive communication deficit, dysphagia (difficulty swallowing), cataract right eye, mood disorder, hallucinations, delusional disorder, anxiety, depression, chronic pain, gastro-esophageal reflux, and hyperlipidemia (high fat content in blood). Review of R8's Minimum Data set (MDS), with an Assessment Reference (ARD) of 02/28/2025, revealed R8 had a Brief Interview for Mental Status (BIMS) of 05 (severe cognitive impairment) out of 10. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement comprehensive resident-centered care plans for one out of 19 residents (R7), resulting in unmet care needs and constant yelling out for help and increase frustration for all residents on hall C.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meaningful, individualized, and engaging activities to one resident (#7) of one reviewed for activities.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the development of a pressure ulcer for one resident (#81) of one residents reviewed for the development of pressure ulcers. Findings Included: Resident #81 (R81) Review of the medical record revealed R81 was admitted to the facility 12/23/2024 with diagnoses that included fracture of left femur, repeated falls, dementia, nutritional deficiency, protein calorie malnutrition, urinary incontinence, and bilateral (right and left) hearing loss. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 2 (severe cognitive impairment) out of 15. Review of section M- Skin Conditions, of the MDS with the same ARD, demonstrated that R81 did not have any pressure ulcers. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional standards for tracheostomy care including physician orders with the size of the tracheostomy for two Residents (#38, #87) of three residents review for respiratory care. Findings Included: Resident #87 (R87) Review of the medical record revealed R87 was admitted was admitted [DATE] with diagnoses that included stroke, respiratory failure, tracheostomy, dysphagia (difficulty swallowing), nutritional deficiency, cardiomyopathy (heart muscle disease), atrial fibrillation, ischemic cardiomyopathy (damaged heart muscle and heart can not pump effectively), asthma, hyperlipidemia (high fat content in blood), tricuspid (heart valve) insufficiency, and hypertension. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident's expressions of distress, developed decreased social interaction, increased withdrawn, anger, and depressive behaviors, and reported possible cause of frustration for one residents (Residents #52) of two residents reviewed for psychosocial distress.

Inspectors wroteThis citation is linked to intake MI00150346 Based on interview and record review the facility failed to ensure that a fall protection mat was at bedside (per care plan) to prevent injury from falls for 1 resident (R8) of 3 residents reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate account of controlled medications for one (R17) of four reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to knock prior to entering resident rooms and failed to ensure a resident was treated with respect and dignity for one (Resident #13) of three reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain an x-ray in a timely manner for 1 (Resident #8) of 3 reviewed for delay of care.

Inspectors wroteThis citation pertains to intake MI00147874 Based on interview and record review the facility failed to provide Cardiopulmonary Resuscitation (CPR) for 1 resident (R200) of 4 residents reviewed who was a full code resulting in Immediate Jeopardy when CPR efforts were not performed at the time resident R200 was found to have no pulse or respirations and this deficient practice has the potential for 44 facility residents not having there full code status wishes honored.

Inspectors wroteThis citation pertains to intake MI00147601 Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 (R201) of 1 resident reviewed which would include interventions as safeguards against swallowing non-food items resulting in the potential for reoccurrence of the behavior.

Inspectors wroteBased on interview and record review, the facility failed to provide ongoing clinical assessments (neurological assessments) for 1 (R203) of 1 resident reviewed for neurological assessments resulting in the potential for lack of recognition of brain injury.

Inspectors wroteThis citation pertains to intake MI00147874 Based on interview and record review the facility failed to reassess the respiratory status of 1 (R200) of 4 residents reviewed resulting in the potential for respiratory failure as cause of death.

Inspectors wroteThis citation pertains to intake MI00146843. Based on interview and record review, the facility failed to ensure written notice was provided prior to room changes for four (Resident #2, #5, #6 and #11) of five reviewed.

Inspectors wroteThis citation pertains to intakes MI00146687 and MI00146843. Based on observation, interview and record review, the facility failed to maintain cleanliness and repair of resident bathrooms.

Inspectors wroteThis citation pertains to intake numbers MI00144590 and MI00144986. Based on interview and record review the facility failed to ensure for two out of three residents (Resident #1 and 3) accurate medical record documentation that reflected the care and services provided and the resident's condition. Findings Included: Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed R1 had signed a Do Not Resuscitate (DNR) document and an Advanced Directive which revealed her wish to not receive resuscitation. Per R1's face sheet she was admitted to the facility on [DATE]. Review of R1's progress notes dated [DATE], revealed the Nurse Practitioner (NP) was notified via telehealth R1 was confused, short of breath, and pale in color. Review of another progress notes dated [DATE], documented by the same NP revealed R1 stated she did not feel right and wanted to go to the hospital. [...]

Inspectors wroteThis citation pertains to Intake MI00143566. Based on interview and record review, the facility failed to ensure medications were administered as ordered for two (Resident #1 and Resident #3) of three reviewed.

Inspectors wroteThis citation pertains to Intake MI00143566. Based on observation, interview, and record review the facility failed to maintain an accurate account of all controlled drugs for three (Resident #1, #2, #3) of three reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper label, dating and storage of foods occurred and dishwasher rinse temperatures were in the appropriate range with 82 residents consuming meals from the kitchen (1 resident receives nothing by mouth) resulting in increased risk of contaminated foods and the risk of food borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure the attending physician documented in the medical record that identified medication review irregularities were reviewed, the action taken, and the rationale for no changes to the medications for five (Resident #7, #14, #18, #55, and #69) of five reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when four medication errors were observed from a total of 27 opportunities for four residents (Resident #23, #49, #50, #179) of four reviewed for medication administration, resulting in a medication error rate of 14.81%.

Inspectors wroteBased on interview and record review, the facility failed to ensure updated and accurate advance directive information was in place for two residents (Resident #14 and Resident #183) of two reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time).

Inspectors wroteBased on interview and record review, the facility failed to communicate, develop, and implement a coordinated plan of care for Hospice Services for one (#183) of one residents reviewed for Hospice services, resulting in uncoordinated care planning.

Inspectors wroteBased on interview and record review, the facility failed to justify the continued use of medications for two (Resident #18 and Resident #55) of five reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to justify the use of PRN (as needed) psychotropic and antipsychotic medications for three (Resident #18, #55, and #69) of five reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a dental appointment for one resident (#60) of one reviewed for dental services.

Inspectors wroteThis Citation Pertains To Intake #MI00141092 and MI00140644 Based on interview and record review the facility failed to ensure allegations of abuse were identified, investigated, and reported for two out of five residents (Resident #4 and #5) resulting in the potential for resident abuse that is not identified, investigated, and reported. Findings Included: Resident #5 (R5): Per the facility face sheet R5 was admitted to the facility on [DATE], however was discharged on 11/11/2023. Review of an audio conversation between R5's roommate, Administrator A, and Director of Nursing (DON) B dated 11/4/2023 at 2:00 PM, revealed R5's roommate told Administrator A, and DON B that R5 would cry out for Jesus to help him and have mercy on him. R5's roommate stated in the audio that a staff member (did not know name) yelled from the hallway for R5 to shut up. [...]