Medilodge of Munising

Inspectors wroteThis citation pertains to intakes #2980097 and #2976728Based on observation, interview, and record review the facility failed to prevent an elopement for one Resident (#10) and failed to ensure safety measures were in place and care planned to prevent elopement and unsafe wandering for three additional Residents (#11, #12, and #13) in four of four residents reviewed for elopement risk.

Inspectors wroteBased on interview and record review, the facility failed to report an elopement which lasted over 25 minutes in dangerous wintery conditions for one Resident (#10) of four Residents reviewed for unsafe wandering.

Inspectors wroteThis citation pertains to intakes #2980097 and #2976728Based on interview and record review the facility failed to ensure that a complete and thorough investigation was completed in a timely manner for an incident of elopement for one Resident (#10) of one resident reviewed for accidents and hazards.

Inspectors wroteBased on interview and record review, the failed to fully implement and operationalize its Abuse Program Policy and Procedure and immediately report to the State Agency allegations and actual resident to resident abuse for 9 Residents (Residents #4, #10, #52, #55, #R63, #100, #101, #102, & #103) from 13 residents reviewed for abuse, resulting in Resident #4 being involved in multiple incidents of resident to resident abuse, the potential for continued abuse and falls with major injury in the facility to go unrecognized, and Resident #4 grabbing on to the wrist of Resident #102, causing pain, fear and increased anxiety.

Inspectors wroteBased on interview and record review, the facility failed to maintain sufficient nursing staff to provide nursing and related services to meet resident needs for 1 (Resident #55) of 18 residents reviewed for staffing, and 6 of 10 residents from a confidential group interview reviewed for call light wait times, nursing care, staffing, and quality of care resulting in feelings of frustration, unmet resident needs and the potential for harm with negative physical, mental and psychosocial outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure evening snacks were offered for six of eight Residents in a confidential group meeting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transport linen, review and update infection control policies annually, and ensure infection prevention and control practices were implemented for two Residents (#3 and #51) of 5 residents reviewed for infection prevention and control. This deficient practice resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 74 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the premises and proper storage of clean and sanitary supplies, resulting in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility. Findings Include:On 1/5/2026 at 9:10 AM, paint was observed peeled off from the wall in room [ROOM NUMBER] behind the bed of the resident. The section was approximately one and a half feet wide by 3 feet high. The baseboard heat cover in this room was also observed to have paint loss in several places. On 1/5/2026 at 11:12 AM, observation of the exterior back door in the maintenance hall showed the door-sweep on the bottom of the exterior door is damaged and daylight is visible below part of the door. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to fully implement and operationalize its Abuse Program Policy and Procedure and immediately identify, report and thoroughly investigate repeated incidents of physical and verbal abuse for 9 Residents (Residents #4, #10, #52, #55, #R63, #100, #101, #102, & #103) from 13 residents reviewed for abuse, resulting in a laceration to Resident #4's forehead, and based on the reasonable person concept would cause feelings of fear and intimidation for Residents #10, and #55. Findings Include:Resident #4 (R4)Review of an admission Record revealed R4, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide information to formulate an advanced directive for one Resident (#74) of one resident reviewed for advanced directives.

Inspectors wroteBased on interview and record review, the facility failed to provide residents/responsible parties with written notifications of bed hold and transfer notifications and/or provide notification to the office of the state Ombudsman for facility initiated transfers, for three Residents (R9, R70, R1) of five residents reviewed for hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure completion of a Level II PASARR (Pre-admission Screening/Annual Resident Review) for one Resident (#13) of one resident reviewed, resulting in the potential for lack of appropriate services for mental disorder [MD] or intellectual disability[ID]).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to revise/updated resident person centered care plans for 1 Resident (#5) of 13 residents reviewed for care planning resulting in unnecessary administration of psychiatric medications for R5, the potential for administration of unnecessary medications without proper indication, and the potential for inadequate goods and services for residents to maintain their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities for one Resident (#74) of two residents reviewed for activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document wounds, determine wound etiology, and adhere to physician's orders for bilateral lower extremity compression devices for one Resident (R51) of 18 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to discontinue an inhaled medication per pharmacy recommendations and physician order for one Resident (#85) failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed pain medications for three Residents (#5, #85, #55) and failed to implement not pharmacological interventions prior to the start of an antipsychotic medication and utilize physician ordered as needed (PRN) anti-anxiety medications for one Resident (#5) of five Residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate at or below five percent (5%), with three errors out of 31 opportunities resulting in a medication error rate of 9.68%, affecting one Resident (#85) of four residents reviewed.

Inspectors wroteThis deficiency pertains to MI00153258 Based on observation, interview, and record review the facility failed to use the appropriately sized sling with the mechanical lift, and provide adequate supervision during a transfer to prevent injury for one Resident (#1) of two residents reviewed for accident/hazards. This deficient practice resulted harm when R1 incurred deep purple bruises on arms and leg, an injured toe, discomfort during transfers and risk of additional injury during transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the receipt and transcription of physician orders for immediate care upon admission of two Residents (R3 & R11) out of 9 residents reviewed for physician orders. This deficient practice resulted in lack of physician orders for necessary medications and treatments, and the potential for worsening of condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure denture care and timely incontinence care were provided for one Resident (R3) of seven residents reviewed for assistance with Activities of Daily Living (ADLs). This deficient practice resulted in R3's inability to use their dentures, per the care plan, and an extended time in a urine saturated brief.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meaningful activities to promote psychosocial well-being for 1 resident (R3) of 4 residents reviewed for activities. This deficient practice resulted in social isolation for R3 who had both visual and bilateral hearing loss.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for wound care for two Residents #6 and #7 of eight residents reviewed for physician orders. This deficient practice resulted in the potential for infection, possible harm to intact skin, and a delay in healing.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care including toenail trimming for four Residents ( #3, #8, #9 and one Confidential Resident [CR]) of four residents reviewed for nail care. This deficient practice resulted in unnecessary pain, untrimmed toenails and the potential for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Securely store an insulin pen following use for 1 Resident ( #1), and 2. Secure 1 of 2 treatment carts reviewed for medication storage This deficient practice resulted in the potential misuse of resident medications and/or treatment supplies.

Inspectors wroteThis citation pertains to Intake #MI00149352. Based on observation, interview, and record review the facility failed to maintain equipment in good working order and failed to clean and sanitize resident equipment, resulting in an increased potential for spread of infections for residents utilizing equipment.

Inspectors wroteThis citation pertains to Intake #MI00149352. Based on interview and record review the facility failed to implement and follow their policy to ensure a safe and orderly discharge was provided for 1 Resident (#2) of 2 residents reviewed for discharge/transfers. This deficient practice resulted in an involuntary discharged into the community without sufficient preparation and orientation with the potential to disrupt the necessary care and services and the potential for homelessness.

Inspectors wroteThis citation pertains to Intake #MI00149718 Based on observation, interview and record review, the facility failed to remove expired foods from the mini-fridge for one Resident (#1) of one resident reviewed for storage of foods brought to residents by family and other visitors. This deficient practice resulted in the potential for expired food to be consumed and increasing the risk of food borne illness.

Inspectors wroteThis citation pertains to MI00148054: Based on interview and record review the facility failed to properly transcribe and administer medications per physicians orders for 1 Resident (#3) of 4 residents reviewed for quality of care, resulting in the lack of assessment, monitoring, and documentation and resulted in hospitalization and subsequent delay in treatment/resolution of the infection with the potential for worsening of condition.

Inspectors wroteThis deficiency pertains to Complaint Intake MI00146981. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three Residents (#29, #22, and #36) of three residents reviewed for wounds. This deficient practice resulted in the deterioration of a left heel pressure injury in one Resident (#29) resulting in gangrene, sepsis, and the need for surgical amputation.

Inspectors wroteThis Deficient Practice Statement (DPS) has two parts: A and B. DPS A: Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in a fall with major injury for one Resident (#64) of five residents reviewed for accident hazards and supervision. This deficient practice resulted in serious bodily injury including a head laceration and a cervical (neck) fracture for Resident #64.

Inspectors wroteThis deficiency pertains to Complaint Intake MI00146981. Based on observation, interview, and record review, the facility failed to provide sufficient staffing to address the care, needs, and safety of the entire facility population. This deficient practice resulted in unmet care needs and the potential for serious safety issues for all 65 residents of the facility.

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 any and all 65 residents of the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to implement enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for EBP. This deficient practice has the potential for development and transmission of Multidrug Resistant Organism (MDRO) infections. Findings Include: On 10/22/24, at 9:49 AM it was noted that there was no EBP outside of room [ROOM NUMBER] for bed A. Bed A was assigned to Resident 274 (R274). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified existence regarding privacy during care by failure to knock on doors or request permission before entering resident's rooms as expressed by 8 Residents (R6, R19, R25, R42, R45, R55, R61, and R67) of 9 residents reviewed for dignity and respect. This deficient practice resulted in frustration, embarrassment, and lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident and Resident Representative in writing with the reason for a transfer out of the facility for four Residents (R124, R22, R29, R64) of four residents reviewed for transfers out of the facility. This deficient practice resulted in the potential for the Resident's Representatives to be uninformed regarding the Resident's conditions and location, as well as a potential for inappropriate discharge/transfers.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to hospital transfer for five residents (Resident #18, Resident #124, Resident #64, Resident #22, and Resident #29) including details of duration of the bed-hold and conditions of readmission.

Inspectors wroteBased on observation, interview, record review, the facility failed to destroy discontinued schedule two medications in a timely manner for three medications carts reviewed of four medication carts for medication storage and used another resident's medication on a different resident. On [DATE] at 1:16 PM, an observation was made of Resident #22 (R22) in their room. R22 was asked if it was alright to look around for their wound care supplies and replied, Yeah, sure go right ahead. In R22's closet an observation was made of another residents acetic acid 1000 milliliters solution. R22 was asked if the facility staff was using the solution on them and replied, Yes, they use that on my lower legs when they wrap them. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dementia training was completed by four of four Certified Nursing Assistants (CNAs) reviewed for annual training requirements. This deficient practice resulted in the potential for unmet care needs and the potential to affect all residents with dementia in a current facility cenus of 65 residents.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from verbal abuse for one resident (R61) of four residents reviewed for abuse. This deficient practice resulted in mental distress and anguish after a staff member suggested the resident end his life.

Inspectors wroteBased on interview and record review the facility failed to report alleged abuse timely for two Residents (R61 and R124) out of four residents reviewed for abuse reporting to the State Agency (SA). This deficient practice resulted in the potential for ongoing abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess two residents (Resident #18, Resident #274) of two residents reviewed for the clinical need for urinary catheterization (a tube placed into the bladder to facilitate bladder drainage), leading to inappropriate or potentially unnecessary catheter usage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring for weight fluctuations for two Residents (R61 and R124) of four residents reviewed for nutritional needs. This deficient practice resulted in the potential for inaccurate assessments, continued weight loss or gain, and physical decline.

Inspectors wroteThis deficient practice has two different DPS's. DPS A and DPS B. DPS A: Based on interview and record review the facility failed to obtain informed consent and obtain physician orders for psychotropic medication for Residents (R19 and R49) of four residents reviewed for unnecessary psychotropic medications. Resident #19 (R19) Review of the Minimum Data Set (MDS) assessment, dated 5/24/24, revealed R19 was admitted to the facility on [DATE] with a primary diagnosis of contact with and suspected exposure to Covid-19. On 10/23/24 at 4:36 PM, review of R19's electronic medical records (EMR) revealed R19 had a physician order for lorazepam 0.5 mg (milligram), give 0.5 mg by mouth every 8 hours as needed for anxiety related to generalized anxiety disorder for 2 weeks, start date 5/9/24 and stop date 5/23/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program that included development, monitoring, and evaluation of adverse events to correct quality deficiencies and maintain sustained compliance. This deficient practice had the potential to affect all 65 residents in the facility. Findings Include: On 10/24/24 at 9:47 AM, an interview was conducted with the Nursing Home Administrator (NHA) who verified that the QAPI meetings were held monthly. When asked if they monitor adverse events, the NHA asked what did I mean? The NHA stated that she receives emails from the regional clinical nurse and the Director of Nursing. The NHA stated that the regional clinical nurse tells her what happened and what they should be doing. [...]

Inspectors wroteThis citation pertains to Intake MI00147081 Based on interview and record review, the facility failed to ensure an accurate indication to administer a laxative prior to administering for one Resident (R901) of one resident reviewed for unnecessary medications.

Inspectors wroteThis deficiency pertains to Intake: MI00146075 Based on interview and record review, the facility failed to provide showers for one Resident (R5) of three residents reviewed for showers.

Inspectors wroteThis deficiency pertains to Intake: MI00146243 Based on observation, interview, and record review, the facility failed to transcribe treatment orders and follow-up on wound clinic recommendations for one Resident (R5) of three residents reviewed for pressure injuries.

Inspectors wroteThis citation pertains to MI00145314 and MI00145704 Based on observation, interview, and record review the facility failed to ensure adequate numbers of staff to meet the needs of four Residents (#1, #3, #7, and #11) of four residents sampled for sufficient staffing. This deficient practice resulted in the potential for a decline in resident quality of life and/or quality of care, not receiving medications timely, and unmet care needs for all seventy-seven residents.

Inspectors wroteThis citation pertains to MI00145314 and MI00145704 Based on observation, interview, and record review, the facility failed to complete and post the daily nurse staffing information. 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 77 residents in the facility.

Inspectors wroteThis citation pertains to MI00145314 Based on observation, interview, and record review the facility failed to 1. Provide Personal Protective Equipment (PPE) that was readily available for staff 2. [NAME] PPE prior to entering a transmission-based precaution room. This deficient practice resulted in the potential for contamination and the spread of illness to residents and staff.

Inspectors wroteThis citation pertains to MI00145704 and MI00145755 Based on interview and record review, the facility failed to investigate the root cause of injuries to three Residents (#5, #3, and #4) of three residents reviewed for resident safety/falls.

Inspectors wroteThis citation pertains to MI00145723 Based on observation, interview and record review, the facility failed to provide adequate medically-related social services to one Resident #2 (R2) of one resident reviewed for social services care. This deficient practice resulted in the potential for psychosocial decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a change in condition for one Resident (R2) of three residents reviewed for a change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer and provide pressure ulcer care per professional standards of practice for two Residents (R4 and R8) of three residents reviewed for pressure ulcer care.

Inspectors wroteBased on observation and interview, the facility failed to maintain two refrigerators used for the storage of food in two nourishment rooms, in a safe and sanitary operating condition. This deficient practice has the potential to result food spoilage or injury to staff using the damaged doors, and had the potential to impact all 64 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience for six Residents (R7, R10, R20, R28, R46, & R49) of 12 residents reviewed for dining. This deficient practice resulted in staff standing over residents while feeding them, lack of adequate feeding assistance & supervision resulting in food spillage and undignified care interactions.

Inspectors wroteBased on interview, and record review, the facility failed to complete a performance review of each nurse aide at least once every 12 months. This deficient practice resulted in the potential for inadequate resident care and unmet resident care needs for all 64 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medication storage room free of expired medications and securely store medications, for one of two medication rooms and two of three medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of medications with reduced intended effect.

Inspectors wroteThis citation is Related to: Intake ID: MI00138873 & MI00139037 Based on observation and interview the facility failed to provide a sanitary and functional environment for residents, staff and visitors as evidenced by: 1. The presence of mold in two shower stalls used by staff to provide showers to residents. 2. Deteriorating walls surrounding a housekeeping floor sink. 3. Broken plastic light fixture shield over a shower enclosure. This deficient practice has the potential to result in the spread of fungus spores and contribute to respiratory irritation/complications to residents and staff using the shower area.

Inspectors wroteThis citation is related to: Intake ID: MI00138630, MI138719 & MI00139905 Based on interview and record review, the facility failed to provide timely showers and toileting assistance for three Residents (R43, R44 and C1) of 17 Residents reviewed for activities of daily living (ADL's) including showers and toileting. This deficient practice resulted in resident dissatisfaction, embarrassment, and the potential for poor hygiene,and uncleanliness.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective bowel management program for one Resident (R16) of one resident reviewed for bowel management. This deficient practice resulted in the potential for a bowel related complications including impaction, obstruction and other bowel related issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure ulcer care per standards of practice for one Resident (R7) of one resident reviewed for wound care/pressure ulcers. This deficient practice resulted in the potential for poor wound healing, infection, and worsening of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication administration error rate less than 5%, for 4 of 25 medication administrations. This deficient practice resulted in a medication administration error rate of 16.00%, with the potential for medical complications related to resident medication treatments for various conditions.