Medilodge of Portage

Inspectors wroteThis citation pertains to intake #2968884, #3004071, and #3000720Based on observation, interview and record review the facility failed to ensure resident received appropriate care for skin breakdown and pressure ulcer development in 2 of 3 residents (Resident #119 and Resident #5) reviewed for pressure ulcers, resulting in Resident #119 developing a pressure ulcer infection and Resident #5 developing pressure ulcers.

Inspectors wroteThis citation pertains to intake # 2790303 & 2968884. Based on interview, and record review, the facility failed to ensure timely response to call lights to meet resident needs in 4 of 5 residents (Resident #8, #14, #58, & #119) reviewed for dignity, and 6 of 13 residents from the confidential group interview, resulting in long call light wait times for incontinence care, frustration, and impaired self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1.) ensure the safety of residents to prevent falls, 2) provide adequate supervision and assistance to prevent falls, and 3.) utilize footrests for wheelchair transport in 3 of 3 residents (Resident #40, #26, and #95) reviewed for accidents and hazards, resulting in Resident #40 having 22 falls over 2 months, Resident #40 and #95 being transferred without wheelchair footrests, and Resident #26 being improperly transferred. This deficient practice placed all 3 residents at risk for injury.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 5/12/26 at 11:01 AM, observation of the D hall closet containing resident slings, found that the slings were hung up by one side on the hangers and left to drag onto the floor. When asked if this is how the slings are normally kept, Housekeeping Manager M stated that it happens all the time and that staff need to hang both sides of the sling up to keep it off the floor. On 5/13/26 at 9:47 AM, observation of the love seat and chair, located on the far side of the dining room, were found with increased accumulation of debris, sand, wrappers, paper trash and a yellow push pin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized activities designed to support the psychosocial well-being of 1 of 1 resident (R65) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, boredom, and depressed mood.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a urinary catheter (tube placed in the body to drain and collect urine from the bladder) was maintained in a sanitary manner for 1 (Resident #122) of 2 residents reviewed for urinary catheters, resulting in the urinary catheter bag lying on the floor creating an opportunity for contamination and the potential for urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received oxygen as ordered in 1 resident of 1 resident (R9) reviewed for oxygen administration, resulting in the potential of respiratory health complications including exacerbation of COPD (chronic obstructive pulmonary disease) and/or retention of carbon dioxide (gas produced by cellular respiration in humans).

Inspectors wroteBased on observation, interview, and record review, the facility failed to (1) ensure medications labeled/dated for 1 resident of 1 resident (R84) reviewed for medication labeling/dating, (2) ensure medications were stored in a secure manner in 2 of 2 treatment carts and 1 medication room/refrigerator (A Hall), resulting in the potential for residents to receive expired medications with altered potency and decreased efficacy, and residents, visitors, and/or staff access the medications, including narcotics, in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate medical records for 1 (Resident #77) of 21 residents reviewed for accurate medical records, resulting in an inaccurate representation of Resident #77's current care needs and the potential for unmet care needs.

Inspectors wroteThis citation pertains to intake #2709386. Based on observation, interview, and record review, the facility failed to provide adequate supervision with hot liquids for 1 resident (Resident #101) of 5 residents reviewed for accidents and safety resulting in Resident #101 receiving a second degree burn (causes pain and damages the outer and second layer of the skin) on her left arm on 12/27/2025 and a burn on her left hand on 12/30/2025 and the fear of receiving another burn.

Inspectors wroteThis citation pertains to intake #2709386. Based on observation, interview and record review, the facility failed to report an incident of neglect (a hot liquid burn) for 1 resident (Resident #101) of 5 residents reviewed for accidents/safety when Resident #101 did not have appropriate interventions in place based on an assessment related to hot liquid spills and did not receive the help she needed resulting in a second burn causing Resident #101 pain, distress and fear of getting burned again.

Inspectors wroteThis citation pertains to Intake: 2575789, 2567564Based on interview and record review, the facility failed to prevent resident to resident sexual abuse in 1 of 3 sampled residents (Resident #102) reviewed for abuse, resulting in the potential for a decline in mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a urinary drainage bag was not resting on the floor to prevent the risk of urinary tract infection for 1 (Resident #101) of 3 residents reviewed for urinary catheter use, resulting in the potential for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare 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 all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure that grievances were promptly documented, investigated and resolved for 9 of 9 residents that participated in the Resident Council (RC) meeting.

Inspectors wroteDuring the RC meeting on 4/8/25 at 10:00 am, 9 of the 9 participants reported the food was always , always cold with overcooked vegetables that were mushy. The RC participants reported items were missing of trays at every meal either a tea bag, salad, bread, dessert, food requests/preferences not honored. RC participants stated the facility had food committee in place, but all 9 RC participants unanimously agreed there had been no improvement. Resident 91 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE], reflected Resident 91 (R91) was admitted to the facility with diagnoses that included sepsis due to escherichia Coli (E. Coli). R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 04/07/25 at 02:27 PM during an interview R91 reported food was terrible, had no flavor and always cold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to dignity with grooming of facial hair in 1 resident (Resident #101) of 5 residents reviewed for dignity resulting in the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on interview and record review, the facility failed to implement ordered restorative program services provided to maintain, increase, or improve range of motion for 1 resident (Resident #41) of 2 residents reviewed for positioning/mobility, resulting in the potential for decreased range of motion and related complications such as development/worsening of contractures (shortening and hardening of muscles, tendons or tissue leading to deformity and rigidity of joints) and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise a person-centered care plan for 1 (Resident #106) of 7 residents reviewed for person-centered care plan revisions resulting in an inaccurate reflection of the resident's current care needs.

Inspectors wroteThis citation pertains to intake #MI00146503 Based on interview and record review the facility failed to ensure that professional standards of nursing practice were maintained related to physician orders for 1 (Resident #100) of 1 resident reviewed for professional nursing standards and physician orders resulting in inaccurate physician orders and the potential for medication error.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper placement of an aspen collar (immobilization brace for the neck) was in place during a transfer for 1 (Resident #105) of 1 resident reviewed for aspen collar use resulting in the potential for re-fracturing, delayed healing and/or potential re-injury.

Inspectors wroteThis citation pertains to intake #MI00146503 Based on interview and record review the facility failed to maintain clear, concise, and accurate medical records for 1 (Resident #100) of 7 residents reviewed for clear, concise, and accurate medical records resulting in inaccurate documentation of medication orders and the potential for a diminished medical outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) specifically face masks, was worn correctly by staff throughout the facility during a covid outbreak, resulting in the potential for the spread of infection and disease transmission for residents residing in the facility.

Inspectors wroteThis citation has two Deficient Practice Statements (DPS). DPS 1 Based on observation, interview, and record review, the facility failed to ensure a safe environment and adequate safety measures for one resident (R9) of 22 residents reviewed for accidents and hazards, resulting in a fall with injury and the potential of additional falls with injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in following areas:

Inspectors wroteBased on observation and interview, the facility failed to provide a safe hand railing on Dogwood Trail, resulting in the potential of injury, affecting all residents with the need of handrail assistance while on that hall, a safe way to stabilize or propel themselves.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity for 1 resident (Resident #6) of 3 reviewed for dignity, resulting in the potential of feelings of embarrassment, loss of self-worth, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was accessible to two residents (R89 and R93) of 22 residents reviewed for accommodations of needs, resulting in the potential of unmeet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments in 1 of 22 residents (Resident #80) reviewed for accuracy of assessments, resulting in an inaccurate reflection of the resident's status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop person centered, comprehensive care plans for 2 residents (Resident #408 and Resident #82) of 22 sample residents reviewed for care planning, resulting in a potential for re-traumatization of a Resident with PTSD (post-traumatic stress disorder), and a potential for unmet care needs for a resident with an implanted medical device.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL) care was provided for 1 (Resident #6 ) of 2 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received care and services that addressed their psychosocial needs in 1 of 3 residents reviewed (Resident #408) for trauma-informed care, resulting in Resident #408 experiencing emotional distress, and thoughts of physical aggression toward others.

Inspectors wroteBased on interview and record review, the facility failed to discontinue psychotropic medications prescribed as needed (PRN), after 14 days and/or document rationale to extend prn psychotropic medication use in 1 of 5 residents (Resident #80) reviewed for unnecessary medications, resulting in the potential for adverse side effects and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure 1). proper hand hygiene was performed during brief change for one resident (R89), 2). adequate condition for cleanliness of personal equipment (R89), and 3). appropriate PPE (Personal Protection Equipment) use in a Transmission-Based Precautions Isolation room, of 22 residents reviewed for infection control, resulting in the potential for bacterial harborage, cross contamination, and the spread of disease to a vulnerable population.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess a resident's skin integrity, and update interventions to prevent the development and worsening of a medical device related pressure ulcers for 1 (Resident #100) of 4 residents reviewed for pressure wounds, resulting in Resident #100 developing unstageable/non-healing pressure ulcers after a cast like boot (for leg fracture) had not been removed for assessment of skin integrity by nursing staff in accordance with physicians orders.

Inspectors wroteBased on interview and record review the facility failed to report and injury of unknown origin in 1 of 1 residents (Resident #100) reviewed for abuse reporting resulting in the potential for further injuries to go undetected , and not reported and/or thoroughly investigated.