Medilodge of Okemos

Inspectors wroteBased on interview and record review, the facility failed to ensure four of 32 Licensed Nurses maintained current cardiopulmonary resuscitation (CPR) certification for Healthcare Providers (HCP), which included a hands-on session, for one (R98) of one reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered timely for nine residents (R2, R3, R17, R26, R28, R43, R58, R90, R101) in a facility census of 92.

Inspectors wroteBased on interview and record review the facility failed to maintain respect and dignity to one resident (Resident #3) of one resident's care and services. Resident #3 (R3)Review of the medical record reflected R3 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses of trigeminal neuralgia, multiple sclerosis, chronic pain syndrome, polyneuropathy, muscle weakness and lack of coordination. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2025, revealed R3 had a Brief Interview of Mental Status (BIMS) of 13 out of 15 (cognitively intact) and is dependent of all care. During an observation and interview on 09/02/2025 at 11:52 AM, R3 stated some of the staff are not very kind, this writer asked if she has told anyone, and R3 stated no not yet, she was going to wait and see if her attitude got any better. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain resident's personal privacy for one resident (resident #6) of one resident reviewed. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis and Type 1 Diabetes Mellitus. According to the Minimum Data Set (MDS) assessment dated [DATE], R6 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). On 9/2/25 at 2:36 PM, R6 was observed in her room, sitting up in a power wheelchair. When interviewed in her room with the door closed, two staff members (at different times), knocked on the door and entered before R6 was able to provide permission to enter her private room. R6 became upset and stated that this happens routinely (staff not respecting her privacy). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide justification for not performing a gradual dose reduction (GDR) for one (R90) of five reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fall for one (R5) of two reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff utilized personal protective equipment (PPE) for one (R70) of one reviewed for Transmission-Based Precautions (TBP).

Inspectors wroteDPS 2) Based on observation, interview and record review the facility failed to ensure an as needed narcan order was in place for one (Resident #348) of 19 reviewed for quality of care resulting in the potential to not receive the opioid reversing medication in a timely manner. Resident #348 (R348) Review of an admission Record revealed Resident #348 (R348) admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome and spinal stenosis. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/3/24, reflected R348 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/10/24 at 10:11 AM, R348 was observed in bed. R348 explained that he had frequent pain and was prescribed medications for pain control. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative services or enabler bars for three residents (R18, R73 and R75) of three residents reviewed for restorative care, out of a total sample of 19 residents, resulting in the potential for residents to decline in their current highest functioning level losing their independence and leading to withdrawal, depression and complications of immobility. Findings Include: Resident #18 (R18) Medical record revealed Resident #18 (R18) was admitted to the facility on [DATE] and readmitted on [DATE] initially with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, Diabetes, Chronic Kidney Disease, Pressure Ulcer of Sacral Region, stage 3, Obesity, Gastrointestinal Hemorrhage, Other Intervertebral Disc Degeneration Lumbar Region and a Spinal Cord injury. [...]

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 31 opportunities for two residents (Resident #43, #60), resulting in a medication error rate of 6.67%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in two resident rooms (Resident #38, #86) resulting in the potential for unsafe access to medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of one residents (Resident #42) received timely dental care to obtain a new set of dentures, resulting in embarrassment and a difficult time eating. Findings Included: In an interview on 9/10/2024 at 2:20 PM, Resident #42 (R42) stated that she had seen the dentist about two months ago, and the dentist told her she needed to get new dentures. R42 said she had not seen the dentist since then and had not had any denture fitting done. R42 was observed to have no visible teeth. R42 stated she wanted dentures as soon as possible because she felt embarrassed having no teeth. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a timely Significant Change Minimum Data Set (MDS) assessment for one (Resident #5) of 18 residents reviewed for MDS assessments, resulting in the potential for untimely/inaccurate care plans and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for two (Resident #22, #30) of 18 residents reviewed for MDS, resulting in the potential for inaccurate care plans and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan in 2 of 18 residents reviewed for care plans (R29 and R54), resulting in unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide physician ordered services and assistance to restore bowel and bladder continence for one Resident (R54) of one reviewed for bowel and bladder, resulting in decrease quality of life, lost sleep, frustration and the potential worsening incontinence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when three medication errors were observed from a total of twenty-five opportunities for two residents (Resident #11 and #64) of six reviewed for medication administration, resulting in a medication error rate of 12% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that prescribed medications were given on time and per physician's orders for one resident (R6) of one reviewed for significant medication error, resulting in several missed doses of Physician ordered prescription eye drops, inaccurate dosing and the potential for preventable decline and/or loss of vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely coordination of dental services for one (Resident #22) of one resident reviewed for dental services, resulting in the potential for untreated and unmet dental needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for two Residents (R6 and R54)) of 18 reviewed for medical records, resulting in untimely entry of provider notes in the medical record, significant medication error and the potential for an inaccurate reflection of resident conditions.

Inspectors wroteBased on interview and record review, the facility failed to offer a pneumococcal vaccine in one of five residents reviewed for vaccinations (Resident #13) resulting in the increased potential for pneumococcal disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store hazardous chemicals (pesticide), resulting in potential access and exposure to chemicals by residents, affecting all residents who independently access the courtyard.