Medilodge of Port Huron

Inspectors wroteBased on interview and record review, the facility failed to offer a Covid-19 vaccination to one resident (R113) out of five reviewed for Covid-19 immunizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a graded hand roll (hand splint used to assist with finger extension) and perform a range of motion (ROM) program for one resident (R74) of one resident reviewed for limited ROM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean environment affecting three residents (R51, R7, and R26) of six residents reviewed for environmental concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers per preference and schedule for one resident (R70) out of three reviewed for showers. Findings Include: On 5/2/2024 at 11:04 AM, R70 was observed sitting in their wheelchair. R70 was interviewed regarding receiving showers per schedule and when requested. R70 stated they do not always receive their showers as scheduled and when they do, the staff rush through them. A review of the medical record revealed that R70 admitted into the facility on 1/15/2024 with the following diagnoses, Pruritus and Anxiety Disorder. Further review of the Minimum Data Set assessment revealed a Brief Interview of Mental status score of 7/15 indicating an impaired cognition. R70 also required assistance with bed mobility and transfers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date a (wound) dressing for one resident (R2) out of one reviewed for skin conditions.

Inspectors wroteThis citation has two deficient practice statements. Deficient practice statement one. Based on observation, interview, and record review the facility failed to secure an oxygen tank for one sampled resident (R46) of seven, reviewed for accidents. On 4/30/24 at 9:22 AM, R46's room was observed with an oxygen tank, that stood free on the floor, inside of a black bag (that clips to the wheelchair), and not in a secured carrier. On 5/01/24 at 9:25 AM, R46's room was observed with an oxygen tank, that was behind a positioning wedge. The tank was leaning against the wall inside of the black bag, and not in a secured carrier. On 5/02/24 at 9:22 AM, R46 was observed in their room and was not able to provide information regarding the oxygen tank due to cognitive impairment. R46's room was observed with the oxygen tank, that was behind a positioning wedge. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and obtain consent for bed rails for one resident (R315) out of one reviewed for bed rails. Findings Include: On 4/30/2024 at 1:43 PM, R315 was observed laying in bed. R315 was noted to have full bed rails installed. R315 stated they do not use the bed rails for turning and repositioning. A review of the medical record revealed that R315 admitted into the facility with the following diagnoses, Lobar Pneumonia and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment of 9/15 indicating an impaired cognition. R315 also required assistance with bed mobility and transfers. Further review of the medical records did not reveal a consent or assessment for the used of the bed rails. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices (handling medication, proper storage of nebulizer mask, and wearing personal protective equipment [PPE] for contact isolation rooms) for two residents (R315 and R60) from a total sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a call light within reach for four (R2, R34, R102, R106) of 24 sampled residents, resulting in impaired resident access to requesting and receiving assistance in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate advance directive information was in place for two residents (R5 and and R47) of two reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: R5 On 2/13/23 at 2:50 PM, a record review was completed for R5 and the advanced directive on file was observed to be incomplete. A review of the form titled Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt. noted, This is to acknowledge that I have been informed, in writing and in a language that I understand, of my rights and all rules and regulations regarding decision concerning medical care, including: [...]

Inspectors wroteThis citation pertains to intake MI00128730. Based on interview and record review, the facility failed to protect a resident's (R89) right to be free from physical abuse by another resident (R373), resulting in the resident getting hit on the shoulder and subsequent feelings of anxiety and psychosocial distress. Findings Include: A review of a Facility Reported Incident (FRI) dated 5/12/2022 revealed the following: Investigation: The incident was not witnessed by staff. Staff answered [R89] call light and [R89] reported that [R373] had hit [them] in the shoulder. A review of the R89's medical record revealed that the resident admitted into the facility on [DATE] with diagnoses of, Chronic Obstructive Pulmonary Disease, Pain, and Major Depressive Disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide follow-up to the PASARR (preadmission screening/annual resident review) form 3877 for two residents (R24 and R77) of three reviewed for PASARR concerns, resulting in the potential for unmet care needs. Findings Include: R77 A review of the medical record revealed that R77 admitted into the facility on 9/23/19 and readmitted on [DATE] with the following diagnoses, Bipolar Disorder, Psychotic Disorder with Delusions, and Schizophrenia. A review of the physician orders revealed that R77 was currently prescribed the following medications, Prozac (antidepressant), Seroquel (antipsychotic), Zyprexa (Antipsychotic), and Ativan(Antianxiety). A review of R77's documents revealed the following Annual Resident Review (ARR) revealed that questions 1-4 were checked yes for Mental Illness and Dementia. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure care plans were revised to reflect the current needs and condition of the resident for four sampled residents (R98, R102, R173, R375) of 24 residents whose care plans were reviewed, resulting in and the potential for unmet care needs.

Inspectors wroteThis citation pertains to Intake MI00133768. Based on observation, interview and record review, the facility failed to ensure interventions to prevent the development of pressure ulcers were implemented for one resident (R102) of four reviewed for skin conditions, resulting in the potential for skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to verify eligibility for and obtain consent (from legal guardian) prior to administering a COVID-19 vaccine for one resident (R24) of five reviewed for immunizations, resulting in the potential for residents and/or resident representatives to not be fully informed of the benefits and potential risks associated with the COVID-19 vaccine.