Medilodge of Sault Ste. Marie

Inspectors wroteThis deficient practice pertains to Intakes 2809637, 3014371, 3014349, 3011210, 3021572, 3021668. Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the highest possible level of physical, mental, and psychological well-being for all 73 residents of the facility as evidenced by:Failure to ensure adequate supervision to prevent a resident-to-resident physical altercation. Failure to respond to call lights within an appropriate time frame. Failure to accommodate resident preferences including sleep/wake schedules. Failure to ensure assistance with activities of daily living (ADLs) including toileting and routine incontinence care.

Inspectors wroteThis citation pertains to Intake 2702621. Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the highest possible level of physical, mental, and psychological well-being for all 86 residents of the facility as evidenced by:Failure to ensure assistance with activities of daily living (ADLs) including routine incontinence care, bathing, shaving, turning and repositioning, and feeding. Failure to accommodate resident preferences including sleep/wake schedules, treatment times, and physical location within the facility. Failure to ensure a timely, dignified, and palatable meal service. Failure to maintain a restorative therapy program. Failure to respond to call lights within an appropriate time frame. [...]

Inspectors wroteThis citation pertains to intake 2702621Based on observation, interview, and record review the facility failed to provide routine incontinence care for one Resident #4 (R4) of two residents reviewed for incontinence care. This deficient practice resulted in harm including anger, frustration, helplessness, and sadness based on the reasonable person concept.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate nurse staffing information was posted on a daily basis, resulting in the potential for all 86 residents and their representatives to be misinformed of current facility staffing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a qualified dietitian, other clinically qualified nutrition professional, and/or director of food and nutrition services who met the required qualifications in the timeframe allowed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During a lunch meal observation on B Hall 2/8/2026 at 1:47 PM, CNA I was moving in and out of resident rooms bringing soiled meal trays back to the food cart for transport to the kitchen to be washed. At 1:51 PM on 2/8/2026, the food cart was observed to have six unserved meal trays remaining inside along with soiled food trays. Some of the soiled trays had been placed above the unserved trays and two soiled trays had been placed on the same shelf next to two unserved trays, touching and blocking service. CNA R looked into the cart and said, I'm not sure who did this. There is not supposed to be dirty trays in with the new trays. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a comprehensive and accurate facility assessment to ensure sufficient staffing levels for all 86 residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. This deficient practice has the potential to affect the safety and quality of life of all 86 residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to incorporate high-risk, high-volume, and high-priority quality concerns from feedback obtained from direct care staff, residents, and resident representatives into an effective Quality Assistance and Process Improvement (QAPI) program. This deficient practice resulted in ongoing quality-of-care concerns and systemic issues in several areas including assistance with activities of daily living (ADLs), incontinence care, prompt and palatable meal service, positioning needs, and honoring resident preferences which had the potential to affect all 86 residents in the facility.

Inspectors wroteThis citation pertains to Intake 2702621. Based on observation, interview, and record review, the facility failed to:Implement Enhanced Barrier Precautions (EBP) in a timely manner for six Residents (#33, #93, #90, #92, #94, & #91). Properly don (put on) personal protective equipment (PPE) prior to entering EBP rooms. Update infection control policies on an annual basis. Maintain sanitary medication and treatment carts. Ensure appropriate hand hygiene during feeding assistance. Ensure separation of unserved food trays and soiled meal trays within transport carts. These deficient practices resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 86 residents in the facility.

Inspectors wroteThis citation pertains to Intake 2702621. Based on observation and interview, the facility failed to maintain general cleanliness and repair of the facility, resulting in an increased potential for contamination and a possible decrease in satisfaction of living to all residents. Findings Include:On 02/08/2026 at 1:34 PM observed a pink Caution Wet Floor sign on the floor sitting next to a waste container with a couple of inches of water in it in in the front entrance foyer across from the front door. The ceiling around the sky light above this area was observed water damaged. On 02/09/2026 at 8:45 AM during interview with Maintenance Director D stated that he has tried a few times to repair the roof but was told that it could void the roof warranty and not to attempt to repair any further. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assist, set up, or place meals within reach for four Residents (#4, #47, #69, and #83) of four residents reviewed for reasonable accommodation of needs. Resident #4 (R4) Review of R4's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/25/23 with diagnoses including malnutrition, depression and anxiety disorder. R4 scored 3 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. During an observation on 2/9/26 at 4:20 p.m., R3's lunch was sitting on her bedside table away from her bed and out of reach of the resident. The sandwich was covered with plastic wrap. During an observation on 2/10/26 at 8:32 a.m., R4 laid in bed with her meal try on the bedside table with the food and beverage covers over her food and beverage items. [...]

Inspectors wroteThis citation pertains to intake 2702621. Based on observation, interview, and record review, the facility failed to provide a homelike dining environment for five of nine residents interviewed in a confidential group meeting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure medications, maintain the security for one medication cart of three medication carts and three of five treatment carts reviewed for medication storage.

Inspectors wroteThis citation pertains to intake 2702621Based on observation, interview, and record review, the facility failed to ensure palatable meals were served at preferred and appetizing temperatures for six of nine residents interviewed in a confidential group meeting, and for one Resident (#93) of one resident who voiced concerns about food temperatures.

Inspectors wroteThis citation pertains to intake #2702621. Based on observation, interview, and record review the facility failed to honor resident food preferences or failed to offer substitutes or alternative menu items for 19 of 24 residents (#4, #6, #12, #13, #22, #23, #24, #30, #31, #37, #R41, #47, #48, #77, & #82) and four Residents in a confidential group meeting) reviewed for nutritional services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dining adaptive equipment for four Residents (#6, #23, #30 & #48) of five residents reviewed for dining assistive devices.

Inspectors wroteBased on observation, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice for three Residents (#10, #12, & #30) of three Resident reviewed for resident choice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate advanced directive information was in place for one Resident (#11) of two residents reviewed for accuracy of advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time).

Inspectors wroteBased on observation and interview, the facility failed to protect the privacy of medical records for one Resident (#99) of one resident reviewed for privacy of medical records.

Inspectors wroteThis deficient practice pertains to intake #2702621 Based on interview and record review, the facility failed to protect one Resident (#93) of one resident reviewed for misappropriation of property.

Inspectors wroteThis deficient practice pertains to intake #2702621 Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (Resident #93) out of one resident reviewed for reporting abuse.

Inspectors wroteBased on interviews and record review, the facility failed to implement policies and procedures for ensuring investigating of an alleged resident misappropriation of medication for one Resident (#93) out of one resident reviewed for investigation of abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician dietary orders for the resident's immediate care for two Residents (#91 & #94) of two records reviewed for admission orders.

Inspectors wroteThis deficient practice pertains to intake 2702621Based on observation, interview, and record review, the facility failed to ensure residents were provided individualized care to promote dignity and enhance their quality of life for three Residents #4 (R4), #47 (R47) and #93 (R93) of five residents reviewed for ADL's.

Inspectors wroteThis citation pertains to intake 2702621. Based on observation, interview and record review, the facility failed to initiate bowel protocol in a timely manner for two Residents (#25 and #69) and failed to complete an assessment upon admission for one Resident (#91) of three residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide restorative therapy services for two Residents (#15 & #83) of two Residents reviewed for restorative therapy needs.

Inspectors wroteThis citation pertains to intake #2702621. Based on observation, interview, and record review, the facility failed to implement fall interventions for one Resident #6 of six residents reviewed for falls and ensure the safety of one Resident #12 for smoking of three residents reviewed for smoking.

Inspectors wroteBased on interview and record review, the facility failed to attempt the use of non-pharmacological interventions prior to administration of PRN (as needed) opioid pain medications for two Residents (#8 & #15) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to ensure implementation of physician orders for hospice services for one Resident (#8) and communication with hospice providers and receipt of hospice documentation for one Resident (#4) of two residents reviewed for hospice services.

Inspectors wroteThis citation pertains to intake 2720794. Based in observation, interview and record review, the facility failed to implement timely interventions to prevent the development and worsening of pressure ulcers for two Residents (#10 and (#14) of three residents reviewed. This deficient practice resulted in R10 developing an unstageable (a severe, full-thickness wound covered with necrotic tissue covering the wound bed causing inability to determine true wound depth) requiring surgical debridement (surgical removal of dead tissue), intravenous (IV) antibiotic therapy and hospitalization.

Inspectors wroteThis citation pertains to intake 2645585. Based on interview and record review, the facility failed to accurately reconcile medications on admission and failed to monitor blood glucose levels according to facility policy and professional standards of practice for one Resident (#10) of three residents reviewed for quality of care.

Inspectors wroteThis citation pertains to intakes 2630912 and 2666718. Based on interview 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 for five Residents (#10, #11, #12, #13, and #16) of five residents reviewed, resulting in the potential for unrecognized and continued abuse.

Inspectors wroteThis citation pertains to intake MI00153461. Based on interview, and record review, the facility failed to implement a timely dressing change to a post-operative surgical area, correctly document an initial skin assessment, and communicate a change in wound condition to facility physician for one resident (Resident #11) of six residents reviewed for quality of care. This deficient practice resulted in a secondary surgery which included an incision and drainage and re-closure of the wound, antibiotics, and hospital admission.

Inspectors wroteThis citation pertains to intake MI00153461. Based on observation, interview, and record review the facility failed to maintain a safe, sanitary community shower room area for the facility population.

Inspectors wroteThis citation pertains to intakes MI00150502 and MI00150541. Based on interview and record review, the facility failed to protect residents' rights to be free from abuse for four Residents (#21, #22, #23, #26) of four residents reviewed for sexual abuse.

Inspectors wroteThis citation pertains to intakes MI00150502 and MI00150541. Based on interview and record review, the facility failed to thoroughly investigate allegations of sexual abuse for one Resident (#20) of one resident reviewed for sexual abuse. This deficient practice resulted in the potential for additional exposure to sexual abuse for cognitively impaired resident, including Residents (#21, #22, #23, #26).

Inspectors wroteBased on interview, and record review the facility failed to maintain sufficient nursing staff as evidenced by confidential resident and family interviews and payroll data analysis. This deficient practice resulted in embarrassment and worry on the part of residents whose needs were not met with potential to impact all 74 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe and sanitary environment for 6 of 6 residents of a total census of 74, who had personal refrigerators in their rooms. This deficient practice has the potential to result in personal food spoilage and contribute to an overall unsanitary condition in the rooms.

Inspectors wroteBased on interview, and record review, the facility failed to ensure care plans were updated promptly and revised appropriately for four Residents (R15, R24, R25, and R36) out of 18 Resident care plans reviewed. This deficient practice resulted in care plans which did not reflect resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately store and label respiratory equipment, provide supplemental oxygen, and provide Continuous Positive Airway Pressure (CPAP) therapy according to physicians' orders for four Residents (#31, #46, #7, and #57) of four residents reviewed for respiratory care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Secure one topical medication, 2. Securely lock a treatment cart and, 3. Store medications properly for one of two medication carts reviewed for medication storage. This deficient practice had the potential for medication errors, drug diversion, and ingestion of medications inappropriate for consumption for cognitively impaired residents.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from verbal abuse for one Resident (#37) of four residents reviewed for abuse. This deficient practice resulted in mental distress and anguish after a staff member used inappropriate language towards a resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one Resident (#25) of one resident reviewed for limited range of motion. This deficient practice had the potential for development and/or worsening of contractures, pain, and skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate medically related social services for one Resident (R36) of four residents reviewed for social services care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure their medication error rate was below 5% when three medication errors were observed from a total of 26 opportunities for one Resident (#7) of two residents reviewed for medication administration. This deficient practice resulted in a medication error rate of 11.54%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective infection control practices and the appropriate use of personal protective equipment (PPE) for two Residents (#9 and #38) of seven residents reviewed for infection prevention and control. This deficient practice resulted in the potential transmission of communicable disease and infectious organisms to all 74 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the contact information for the Office of the State Long-Term Care Ombudsman was posted in a form and manner accessible to residents and resident representatives. This deficient practice affected all 74 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to reflect the actual hours worked by nursing staff (nurses and certified nursing assistants), this has the potential to affect all 74 residents within the facility. This deficient practice resulted in necessary staffing information not being available to residents and visitors.

Inspectors wroteThis deficiency pertains to Facility Reported Incident (FRI) MI00145815. Based on observation, interview, and record review, the facility failed to prevent, detect, and respond to an elopement resulting in the likelihood of serious harm, injury, impairment, or death for two Residents #4 and #5 (R4, R5) of three residents reviewed for elopement. Findings Include: The Immediate Jeopardy began on 7/13/24 at 6:18 PM when R4 and R5 eloped from the facility undetected and whose location was subsequently identified and reported to be on a thoroughfare by a facility visitor. Regional Director of Operations F was notified of the immediate jeopardy on 7/25/24 at 4:27 PM. At that time, a written plan of correction for removal was requested from the facility. [...]

Inspectors wroteThis deficiency pertains to Complaint Intake MI00145750 and Facility Reported Incident (FRI) MI00145875. Based on observation, interview, and record review, the facility failed to prevent two separate incidents of resident-to-resident sexual abuse for four Residents (Residents #1, #2, #4, and #5) of nine residents reviewed for abuse and neglect. This deficient practice resulted in psychosocial harm when Resident #2 experienced ongoing feelings of embarrassment, anxiety, and fear. Findings Include: Resident #2 (R2): Review of R2's electronic medical record (EMR) revealed initial admission to the facility on 3/16/21 with diagnoses including quadriplegia (paralysis that affects all limbs and body from the neck down), dysarthria (difficulty speaking), adjustment disorder with anxiety, and post-traumatic stress disorder (PTSD). [...]

Inspectors wroteThis deficiency pertains to Complaint Intake MI00145457. Based on interview and record review, the facility failed to report an employee's criminal conviction to the Stage Agency (SA). This deficient practice resulted in the potential to jeopardize the safety and welfare of all 69 residents of the facility.

Inspectors wroteThis deficiency pertains to Complaint Intakes MI00145340 and MI00145457. 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 69 residents of the facility.

Inspectors wroteThis deficiency pertains to Complaint Intake MI00145750. This Deficient Practice Statement (DPS) has two parts: A and B. DPS A: Based on interview and record review, the facility failed to report an allegation of potential sexual abuse for one Resident (#5) of nine residents reviewed for abuse. This deficient practice resulted in no investigation into the allegation of abuse by the State Agency (SA) and the potential for continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of potential sexual abuse between two Residents (Residents #4 and #5) of nine residents reviewed for abuse.

Inspectors wroteThis citation pertains to MI00145233. Based on observation, interview, and record review, the facility failed to provide meals at regular times in accordance with resident preferences and expectations for five residents (R2, R4, R6, R12 and R13) of 8 residents reviewed for timely meal delivery. This deficient practice resulted in frustrated hungry residents.

Inspectors wroteThis citation pertains to MI000145229: Based on interview, and record review, the facility failed to implement its policy and assure the timely administration and physician notification of unavailable ordered medications for two residents (R1 and R11) from a total sample of 3 residents reviewed for medication administration. This deficient practice resulted in delayed administration of ordered antibiotics without physician notification to combat known infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with injury for one Resident (R3) of three residents reviewed for falls. This deficient practice resulted in hospitalization where R3 required ten staples placed in the back of his head to close a laceration and then subsequently required transfer to a higher level of care hospital due to a subdural hematoma requiring an intensive care stay.

Inspectors wroteThis deficient practice has two different DPS statements labeled part A and B. DPS A Based on observation, interview, and record review the facility failed to properly don personal protective equipment (PPE) for three Residents (R3, R9, and R10) who were placed in Enhanced Barrier Precaution (EBP) rooms of three reviewed for infection control. This citation is linked to intakes MI00142467 AND MI00142753. On 4/16/24 at 12:35 PM, an interview was conducted with Complainant M and was asked about the nature of the allegations. Complainant M replied, There was an isolation room near my room in the same hallway and staff was not putting on protective gowns or shields and I am not sure what the person had. I think maybe Covid-19, but then they would come and assist me. I don't feel like that was right. The staff should have been wearing protection. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain physician order for indwelling catheter device for one Resident (R3) of three reviewed for bowel and bladder care. On 4/17/24 at 11:00 AM, an observation was made of R3 in his room lying in his bed with an indwelling catheter bag hanging off the left side of his bed. On 4/17/24 at 12:20 PM, an interview was conducted with Certified Nurse Aide (CNA) H and was asked why R3 had an indwelling urinary catheter and replied, I would have to ask the nurse, but he has had it ever since he came back from the hospital. Review of R3's progress notes, dated 3/18/24 through 4/17/24, revealed, an original admission on [DATE] to the facility, a transfer out to a local hospital on 3/26/24, and a return to the facility on 3/28/24. [...]

Inspectors wroteThis Deficient Practice Statement (DPS) has two parts: A and B. DPS A: This deficiency pertains to Facility Reported Incident (FRI) MI00142212. Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in an elopement with the likely serious harm, injury, impairment or death for one Resident (#49) of one resident reviewed for accidents/hazards. Findings Include: The Immediate Jeopardy began on 1/10/24 at 7:23AM when R49 was observed ambulating northbound in a southbound lane by an employee (Staff V) driving into work. Regional Senior Administrator GG was notified of the immediate jeopardy on 1/23/24 at 4:40PM. At that time, a written plan of correction for removal was requested from the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure exhaust ventilation was functioning in resident bathrooms, on two halls, serving 48 of a total 64 residents. This deficient practice has the potential to result in noxious odors permeating the resident environment rendering the living conditions unpleasant and uncomfortable.

Inspectors wroteBased on interview and record review the facility failed to ensure the exercise of resident rights for one Resident (R170) of 17 residents reviewed for resident rights. This deficient practice prevented R170 from exercising her resident right and desire to have family members present during a telehealth visit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accuracy of a Minimum Data Set (MDS) assessment, quarterly nursing assessments (including elopement and fall risk assessments), and nutritional assessments for two residents (Resident #49 and #31) of 16 sampled residents reviewed for comprehensive assessments. This deficient practice resulted in the potential for unmet care needs including inadequate supervision to prevent elopement and inadequate nutritional interventions to prevent unnecessary weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate Quality of Care per professional standards of practice for one Resident (R9) of two residents reviewed for quality of care for adequate seating and positioning for pressure relief and completion of activities of daily living (adls). This deficient practice resulted in pain and feelings of frustration and helplessness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hygienic catheter care and services to prevent urinary tract infections (UTIs) for one Resident (R29) of two residents reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of infectious organisms and the increased likelihood of UTIs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement nutritional interventions for one (Resident #31) of sixteen residents reviewed for nutrition and hydration. This deficient practice resulted in the potential for unnecessary weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified and involved in implementing nutritional interventions for significant weight loss in one (Resident #31) of 16 sampled residents. This deficient practice resulted in the lack of physician coordination related to nutritional decline. Findings Include: Resident #31 (R31): Review of R31's electronic medical record (EMR) revealed initial admission the facility on 12/4/23 with diagnoses including fracture of the right femur, congestive heart failure, and osteoporosis (a condition in which bones become weak and brittle). Review of R31's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to acquire and administer medications to meet the need of two Residents (R26 & R58) of five residents reviewed during medication administration observation. This deficient practice resulted in the potential for infection and adverse medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than five percent with three observed medication errors out of 26 opportunities. This deficient practice resulted in a medication error rate of 11.5 percent and an increased likelihood for medications to be improperly prepared, administered, and/or omitted from residents' medication regimens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for one (Resident #16) of one residents reviewed for Enhanced Barrier Precautions (EBP). This deficient practice resulted in the potential for the spread of infectious organisms to a vulnerable resident.

Inspectors wroteThis deficiency pertains to Facility Reported Incident (FRI) MI00142212. Based on interview and record review, the facility failed to maintain a compliance and ethics program for one (Resident #49) of one residents reviewed for a Facility Reported Incident. This deficient practice resulted in an inaccurate depiction of a facility reported elopement incident to the State Agency (SA).

Inspectors wroteThis Citation Pertains to Intake Number: MI00138909 Based on interview and record review the facility failed to properly assess, stage, and implement treatment for newly developed pressure ulcers for two Residents (R1 and R2) of two residents reviewed for pressure ulcers. This deficient practice resulted in delay in treatment and the potential for worsening pressure ulcers.