Medilodge of Port Huron

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: On 5/19/25 at 11:39 AM, R74 was observed in bed with their right middle and ring fingers flexed unable to easily straighten. When asked if they wore a brace R74 stated, I have a thing for my hand, but no one is putting it on. At 2:00 PM, R74 was observed in bed not wearing a hand splint. On 5/20/25 at 10:30 AM, R74 was observed in bed not wearing a hand splint and confirmed no one has been in to work with their hand. Record review of R74's Electronic Health Record (EHR) revealed the most recent admission to the facility on 7/17/2023 with diagnoses that included contracture of unidentified muscle, generalized muscle weakness, and acquired absence of left hip joint. Review of the Minimum Data Set (MDS) assessment dated [DATE] for R74…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R51 On 04/30/24 at 9:10 AM, R 51 was observed lying in bed in their room. R51's bed was observed adjacent to the wall, with a patch of peeling paint/cracks approximately the size of a basketball. On 05/01/24 at 9:09 AM, R51 was observed lying in bed and was asked about the peeling paint on the wall. R51 stated, Don't like it. A record review of R51's medical record revealed, R51 was admitted on [DATE] with diagnoses of Dementia, Schizophrenia, and Unspecified Intellectual Disabilities. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] noted, R51's Brief Interview for Mental Status (BIMS) score of 11, which indicates mild cognitive impairment. R7 On 04/30/24 at 9:25 AM, R7 was observed lying in bed in their room watching television. There was an area behind the head of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Further review of R70's shower documentation for March 2024 and April 2024 revealed that R70 did not receive a shower on the following days; 3/2, 3/6, 3/9, 3/13, 3/16, 3/20, 3/23, 3/27, 3/30, 4/4, 4/9, 4/16, 4/19, 4/23, 4/26, and 4/30/24. Documentation on these days revealed, Response…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Finding include: On 4/30/2024 at 9:30 AM, R2 was observed sitting in their wheelchair. R2 was noted to have a dressing on their lower left leg. The dressing was not dated. R2 stated they have problems with their legs and the nurse's put dressings on them. R2 stated they have sores on their legs sometimes and they bleed. R2 was also noted to have cream on their feet and paper towels in their shoes. On 5/1/2024 at 10:05 AM and at 5/2/2024 at 9:07 AM, R2 was observed with an undated dressing to their lower left leg. The dressing appeared to be soiled. R2 stated the dressing has not been changed since I spoke to them on 4/30/2024. R2 stated they do not remember when it was last changed or when it was put on. A review of the medical record revealed that R2 admitted into the facility on 7/4/2023 with the following diagnoses, Cerebral Infarction and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This 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. The tank was leaning against the wall inside of the black bag, and not in a secured carrier. On 5/02/24 at 9:23 AM, Unit Manager A was asked and alerted about the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. On 5/2/2024 at 9:04 AM, an interview was conducted with the Registered Nurse (RN) D. RN D stated that when someone gets bed rails, they complete three assessments, and they obtain a consent. RN D stated R315 was not supposed to have bed rails and they had not been assessed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: On 5/1/2024 at 6:32 AM, medication administration was completed with Licensed Practical Nurse (LPN) F. LPN F was observed taking a pill out of the medication cup with their hands without first performing hand hygiene or wearing gloves. On 5/2/2024 at 9:25 AM, medication administration was completed with Licensed Practical Nurse (LPN) G. LPN G was observed breaking a pill in half with their hands without first performing hand hygiene or wearing gloves. On 5/1/2024 at 11:00 AM, an interview was conducted with the Infection Control Preventionist (ICP). ICP stated the nurses should absolutely complete hand hygiene and should not handle anything going in someone's mouth without gloves. R315 On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R2 Review of the facility record for R2 revealed an admission date of [DATE] with diagnoses that included Alzheimer's disease, Schizophrenia and Traumatic brain injury. Minimum Data Set (MDS) assessment indicated R2 required primarily set-up to supervision assistance from staff for self care and mobility. Brief Interview of Mental Status (BIMS) score was 10 indicating moderate cognitive impairment. On [DATE] at 11:00 AM, R2 was initially interviewed in their room. There was no call light visible in the room and the call light wall jack was empty. No hand bell or other call light alternative was observed. On [DATE] at 10:30 AM, No call light was observed in R2's room. R2 was asked about the lack of a call light in the room and stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: the right to accept or refuse medical or surgical treatment. The right to formulate and to issues Advance Directives to be followed should I become incapacitated. (Box Checked) I have chosen to formulate and issue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This 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. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderately impaired cognition. R89 also required extensive two-person assist with transfers. On 2/14/2023 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Further review of the ARR noted the following, Distribution: If any answer to items 1-6 in SECTION II is Yes, send ONE copy to the local…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R98 On 02/13/23 at 12:50 PM, R98 was observed to be in bed laying on their back with the head of the bed up around 30-45 degrees. R98 reported poor control of their urine when they had to go. R98 verbalized they were often incontinent and would have to call staff to come in and change their incontinence brief. R98 then reported they were currently wet and had told staff, and staff said they would change them before lunch. Staff was not observed to provide care prior to R98 having received their lunch. R98 further mentioned that when they were admitted into the facility they had a tube into their bladder (indwelling urinary catheter-tube into the bladder to collect urine) to help them…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This 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. Findings include: On 2/13/23 at 9:21 AM, R102 was observed asleep in bed. Two green protective heel boots were observed sitting in a chair near R102's bed and night stand. An observation of R102's feet revealed R102 was also wearing heel protector boots on their feet. On 2/14/23 at 9:27 AM, R102 was observed in bed. R102's was observed with a wedge under their knees but with their feet laying on the ma. The green heel boots were observed on the floor next to the bed. On 2/14/23 at 2:46 PM, R102 was observed in bed, and the boots remained on the floor and not on R102's feet. RN D walked by the room and was asked when R102 is to have the boots on and stated, We should have them (resident's feet) floated (off…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: A review of R24's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on 9/20/21 and most recently re-admitted on [DATE]. R24 was assessed to have a moderately impaired cognition with medical diagnoses of Stroke, Dementia, Anxiety, Depression, and Psychotic Disorder. Further review revealed that the resident requires extensive assistance from staff for most activities of daily living (ADLs). R24's record indicated that the resident has a legal guardian who is responsible for making their medical and financial decisions. On 2/14/23 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.