Medilodge of Cass City

In the surveyor’s words

From the most serious findings on record at Medilodge of Cass City, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 14, 2021

  This Citation Pertains to Intake MI 179. Based on observation, interview and record review, the facility failed to ensure that policies and procedures were implemented to ensure assessment and interventions for pressure ulcer (wounds caused by pressure) prevention were implemented, per professional standards of practice, for three residents (Resident #701, Resident #707, and Resident #709) of six residents reviewed. This deficient practice resulted in the lack of monitoring of alternating air mattress (pressure reduction mattress) settings and resulted in the following: 1) Resident #701's pressure ulcer worsening, hospitalization , and a potential contribution to death, 2) Resident #707 developing Deep Tissue Injury (DTI) pressure ulcers (unknown depth), and 3) Resident #709 developing a… […]

• Actual harm, isolatedF686Jul 23, 2021

  This Citation Pertains to Intake Numbers: MI 598, MI 031, and MI 039 Based on interview and record review, the facility failed to ensure pressure ulcers were assessed, monitored, and appropriate interventions were in place for one resident (Resident #1) of three residents reviewed for pressure ulcers from a total sample of six residents, resulting in Resident #1 developing a facility-acquired pressure ulcer on the right buttocks that progressed and extended to the bone with black necrotic (dead) tissue. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set (MDS) assessment, dated 7/6/21, indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of the premise's plumbing. Findings include: On 08/26/2025 at approximately 1:00-1:30PM during the environmental tour with the Director of Maintenance D observed drain line to water softener sitting inside drain located in B hall. 08/26/2025 at approximately 1:00-1:30PM conducted interview with Director of Maintenance D on flushing water lines, he stated that the boiler is flushed, and it's done every month. On 08/26/2025 at approximately 1:00-2:00PM record review of legionella results showed legionella positive in C utility room, result was 0.8 CFU/mL on 3/14/25. […]

• No harm, potential for more than minimal, widespreadF812Sep 14, 2023

  Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure safe and sanitary food storage, sanitary conditions in the kitchen, and ensure kitchen equipment was maintained and inspected, resulting in the potential for equipment malfunction, injury, and foodborne illness for all residents who consume food from the kitchen. Findings include: A tour of the facility kitchen began on [DATE] at 10:14 AM with Dietary Manager L. During the tour, the following items were identified in the Egg Fridge: - A container of diced tomatoes labeled as expired: ,d+[DATE]. When asked, Dietary Manager L indicated the tomatoes should not be in the fridge and proceeded to remove them. […]

• No harm, potential for more than minimal, widespreadF725Sep 24, 2021

  Based on observation, interview, and record review, the facility failed to provide sufficient staffing to to meet residents' needs in a timely manner for 6 of 9 residents in the Confidential Group, Resident #6, Resident #51, and one Resident residing on the C-Hall. and 3 residents on the D-Hall, resulting in lack of Activities of Daily Living (ADL) care (oral hygiene, greasy hair), lack of Restorative Services, complaints of long call light response times, episodes of incontinence, anger, frustration, unmet needs, improper positioning, and complaints about not enough staff made to State Surveyors, with the likelihood to affect all residents residing in the facility. […]