Medilodge Of Rogers City

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain plumbing in the building, as observed during a facility tour with maintenance employee C. On 05/27/2026 at 9:45 AM, the beauty shop style sink with a head rest and hair rinse hose was observed leaking where the faucet connects to the sink, and maintenance employee C also observed the faucet leaking and stated they were not aware it needed repair. Later, on 05/27/2026 at 10:16 AM, the sink in the soiled linens room in the D/F Hall was observed with a swivel faucet that was loose and leaking when the sink was turned on, and maintenance employee C confirmed this observation during interview at the time.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess, monitor, and treat changes in respiratory, skin, and bowel patterns for four residents, resulting in significant declines in their health status. For one resident with Parkinson's disease, dementia, and dysphagia, there was a documented decline in transfer ability, eating, and alertness, which ultimately led to delayed response and hospitalization for pneumonia. Despite clear signs of respiratory distress, including increased lethargy, abnormal lung sounds, and suspected aspiration, there was no timely follow-up testing such as a chest x-ray, and comprehensive nursing assessments were not completed after a change in condition was identified. Documentation gaps and delays in physician notification were also noted, with staff failing to initiate pertinent charting or monitoring for infection after the resident's condition changed. Another resident with diabetes and dementia had a chronic, non-healing wound on the nose that was not assessed, monitored, or treated according to facility protocols. The wound, which was present for at least six months and exhibited characteristics that could indicate skin cancer or infection, was not documented in the electronic medical record, and there was no evidence of physician notification or wound evaluation. Staff interviews revealed a lack of awareness and follow-up regarding the wound, and the resident was only placed on a provider assessment list after the issue was raised during the survey. Additionally, the facility failed to appropriately monitor and treat constipation for three residents, despite physician orders and care plan interventions. Documentation showed prolonged periods without bowel movements, and as-needed medications for constipation were not administered according to orders. The facility lacked a policy or protocol for constipation management, and alerts in the electronic medical record were not consistently acted upon. Interviews with the DON confirmed that staff did not follow standard practices for monitoring bowel elimination and initiating interventions after three days without a bowel movement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the resident's representative (DPOA) of a change in condition that required testing and treatment for a urinary tract infection (UTI) in one resident. The resident, who had a primary diagnosis of bipolar disorder and was dependent on staff for toileting and hygiene, exhibited symptoms such as behavioral changes, cloudy urine, burning sensation during urination, urgency, frequency, and dysuria. A physician ordered a urinalysis with culture and sensitivity, which confirmed the presence of infection, and subsequently ordered a course of intramuscular antibiotics. Despite these significant changes in the resident's condition and the initiation of new treatment, there was no documentation in the electronic medical record that the DPOA was notified of the symptoms, testing, results, or the antibiotic therapy. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the expectation was for immediate notification of the resident's representative in such circumstances, with documentation in the progress notes. The DPOA also confirmed not being informed by staff about the resident's change in condition, testing, or treatment, learning of these events only from the resident during a subsequent hospital visit. The facility's policy required prompt notification of the resident's representative when there is a change requiring such notification, including new treatments, but this was not followed in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with requirements regarding the use of PRN (as needed) psychotropic medications for a resident with severe cognitive impairment and a diagnosis of unspecified dementia. Specifically, the facility did not limit the duration of a PRN Xanax order to 14 days, nor did it ensure that the physician documented a rationale for extending the use of the medication beyond this period. The resident's medical record lacked evidence of physician re-evaluation or documentation supporting continued use of the PRN psychotropic medication after the initial 14-day period, despite repeated administrations over several weeks. Additionally, the facility did not document the behavioral symptoms that led to the administration of the PRN Xanax or any non-pharmacological interventions attempted prior to its use. Review of the electronic medical record, progress notes, and medication administration records did not reveal any such documentation. The facility's own policies required documentation of indications for psychotropic drug use, behavioral symptoms, and non-pharmacological interventions, but these were not followed in this case. The pharmacist's medication regimen review also did not address the ongoing PRN Xanax order.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain a physician's order for a resident to perform independent urinary self-catheterization and did not conduct or document an assessment to ensure the resident could safely and sanitarily perform this procedure. Observations revealed that the resident was using a straight catheter kit, and interviews with the DON confirmed that there was no physician order or documentation of an assessment or progress note regarding the resident's ability to self-catheterize. Review of the resident's medical record from the relevant period showed no evidence of a nursing assessment for safe and sanitary self-catheterization, nor any physician authorization for the practice. The resident in question was admitted with a history of being unable to void and was noted to be able to self-catheterize, but also had some urine leakage and required supervision for toileting due to unsteadiness. The care plan indicated a need for self-catheter use and included interventions for assistance and monitoring for UTI symptoms, but did not address the lack of a physician order or assessment for self-catheterization. Facility guidelines for self-intermittent catheterization emphasized safety, comfort, and adherence to protocols, but these were not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a registered nurse (RN) failed to accurately transcribe a medication order for a newly admitted resident who was transferred from a hospital for rehabilitation. The resident, who was alert but confused and mostly nonverbal, was prescribed Metoprolol Succinate ER 25 mg to be administered once daily according to hospital discharge instructions. However, the medication was incorrectly entered into the electronic medical record as 25 mg twice daily, resulting in the resident receiving three extra doses of the medication. The error was identified through a review of the resident's progress notes and medication administration record, which showed a discrepancy between the hospital order and the facility's transcription. Further review revealed that the nurse responsible for the transcription error had a documented history of similar medication errors, including previous incidents involving incorrect medication entry, failure to report errors promptly, and administration of medications to the wrong resident. The facility's policy required a second nurse to double-check medication orders against the original list, but this process was not followed. The nurse had not completed required education on medication error prevention prior to working additional shifts after the incident, and documentation of previous corrective actions was incomplete.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an environment free from abuse for three residents, resulting in multiple incidents of resident-to-resident physical and verbal abuse. One resident with a history of severe cognitive impairment and behavioral symptoms, including physical and verbal aggression, was involved in several altercations with other residents. Documentation and staff interviews confirmed that this resident exhibited aggressive behaviors such as yelling, pushing, slapping, and making threats toward other residents over a period of several weeks. These behaviors were observed in various settings, including the hallway, dining room, and shared bathrooms, and were witnessed by staff and other residents. Specific incidents included the resident pushing another resident in the chest after being provoked, grabbing and attempting to pull a resident off the toilet, slapping another resident across the face, and swatting a resident in the head in the dining room. Progress notes and staff interviews indicated that the resident's aggressive behaviors were ongoing and that other residents expressed fear and distress as a result. The aggressive resident was noted to be ambulatory and able to move quickly, which contributed to the difficulty in preventing these incidents. Staff reported that the resident's behaviors were well-known and that many residents would avoid common areas or seek proximity to the nurses' station when the resident was present. Despite the resident's documented history of aggression and the facility's policy prohibiting abuse, the facility did not effectively prevent repeated episodes of physical and verbal abuse between residents. The ongoing nature of the behaviors, the frequency of altercations, and the impact on other residents' sense of safety and well-being were substantiated through interviews, progress notes, and incident reports. The facility's failure to prevent these incidents resulted in a deficiency related to the requirement to maintain an environment free from abuse, neglect, and exploitation.

Plan Of Correction

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements. Element 1: Resident R1 is currently safe in facility. A psych tele-visit was completed on 4-28-25 and recommendations being reviewed. A medication review was requested on 5-2-25. Facility met with guardian on 4-25-25 related to R1 decline. Guardian declined change in Advanced Directive and hospice services at this time. R1 was sent to ED on 4-30-25 after presenting with a significant decline related to dementia diagnosis. Facility will continue to monitor R1 through documented target behaviors, 24 hour report, and staff reporting. R1 has had no reportable incidents with other residents since 2-10-25. Resident R2 is currently safe in facility. A chart review was completed and plan of care is current as written. Resident R6 is no longer in facility. Element 2: All residents have the potential to be affected. Facility has completed a 7 day look back on resident skin assessments with a BIMS of 8 or below. Residents with a BIMS of 9 or above have been interviewed to ensure they feel safe in facility and have no concerns related to other residents. IDT reviewed interviews and no concerns related to other residents were identified. Facility identified residents with behaviors affecting others and care plans and interventions have been reviewed and are current as written. Element 3: Re-education will be completed by 5-8-25 or before next shift worked with all staff related to the Abuse and Neglect Policy and behaviors affecting others. Administrator and Director of Nursing have reviewed the Abuse and Neglect Policy and deemed it appropriate. Element 4: Random audits of 5 interviewable residents and 5 non-interviewable residents will be completed weekly for 4 weeks. 10 staff members weekly for 4 weeks will be quizzed on how to manage behaviors and offer support to residents. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator and Director of Nursing are responsible for achieving and sustaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to identify and implement corrective action in response to the mechanical dish machine's failure to demonstrate proper sanitizing. During an observation, Kitchen Staff B was seen placing soiled dishes into the dish machine and was asked to demonstrate that the food contact surfaces were reaching the required 160 F for proper sanitizing. The Maximum Registering Temperature (MRT) puck used to measure the temperature read 159 F and 154 F in two consecutive runs, which were below the required 160 F. Despite this, Staff B continued to remove and store the dishes. The dish machine's dial thermometer inaccurately reported a final rinse temperature of 190 F, even though no steam was observed coming from the machine. The Registered Dietitian (RD A) attempted to rectify the situation by running the dishes through the machine again, but the MRT readings continued to be below the required temperature, with one reading as low as 143 F. The facility did not have any backup or alternate quality assurance device to verify the MRT's accuracy or to use in its place if it failed. The FDA Food Code 2017 specifies that equipment food-contact surfaces and utensils must be sanitized in hot water mechanical operations by achieving a utensil surface temperature of 160 F as measured by an irreversible registering temperature indicator. The facility's failure to meet this standard was evident as the MRT consistently showed temperatures below 160 F, and the dish machine's thermometer inaccurately reported higher temperatures. This deficiency was observed during the survey, and the facility did not have a contingency plan or additional quality assurance measures in place to address the issue promptly.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to evaluate the removal of a urinary catheter and ensure urology services were provided for a resident. The resident, who was admitted with a catheter, expressed a desire to have it removed and did not understand why it had not been taken out. The Director of Nursing (DON) acknowledged that the facility had not attempted to remove the catheter since the resident's admission and that there was no medical reason or clinical condition justifying the continued use of the catheter. Additionally, the facility had not offered or arranged a urology appointment for the resident. The resident's medical history included anemia, hypertension, diabetes mellitus, arthritis, anxiety, and depression, with intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). The resident had been hospitalized earlier in the year due to pneumonia and a urinary tract infection (UTI), which was attributed to the catheter. Despite this, the facility did not assess the necessity of the catheter or follow its policy on the appropriate use of indwelling catheters, which mandates assessment for removal unless clinically necessary.