Medilodge of GTC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jan 7, 2026

  This deficient practice pertains to Intakes 2704447 and 2691458.Based on interview and record review, the facility failed to perform timely emergency medical care and Cardiopulmonary Resuscitation (CPR) for one Resident (#1) of five residents reviewed for quality of care, resulting in the death of Resident #1.Findings include:The Immediate Jeopardy (IJ) began on 12/7/25 at 9:15 AM when Registered Nurse (RN) Q discovered R1 without pulse or respirations and failed to initiate emergency life-sustaining measures resulting in the death of R1 at 9:51 AM on 12/7/25 despite his designated full code status. The Nursing Home Administrator (NHA) was notified of the IJ on 1/6/26 at 12:27 PM. At that time, a written immediacy removal plan was requested from the facility. […]

• Immediate jeopardy, isolatedF689May 20, 2024

  This deficiency pertains to Facility Reported Incident (FRI) #MI00144562. Based on observation, interview, and record review, the facility failed to provide adequate supervision per the plan of care for three residents (Residents #508, #509, and #510) during mealtimes. This deficient practice resulted in two choking/aspiration events for Resident #509 which resulted in hospitalization and subsequent death. Findings Include: The Immediate Jeopardy began on [DATE] at 2:40 PM when the facility failed to provide supervision during a mealtime for a resident (Resident #508) with a known history of choking/aspiration. This resulted in R508 experiencing a choking event in his room. […]

• Actual harm, patternF880Oct 24, 2025

  This deficient practice pertains to Intake 2647525.Based on interview and record review, the facility failed to implement infection control measures and ensure comprehensive infection surveillance to prevent the transmission of scabies (a highly contagious skin condition caused by parasitic itch mites that burrow into the skin). This deficient practice resulted in transmission of scabies with associated physical discomfort for six Residents (#2, #3, #4, #5, #6, #7) of twenty residents reviewed for infection control.Findings include:Resident #2 (R2)Review of R2's EMR revealed initial admission to the facility on 7/13/20 with diagnoses including anoxic brain damage and cognitive communication deficit.On 10/22/25 at 1:44 PM, a telephone interview was conducted with Family Member (FM) K… […]

• Actual harm, isolatedF686Aug 6, 2026

  This citation pertains to intake #3095103Based on observation, interview and record review, the facility failed to accurately assess, document, provide appropriate treatment, and update nursing interventions resulting in the worsening of existing pressure injuries and the development a new pressure injury for 1 of 3 sampled residents (R100) for pressure injuries. R100 experienced a new pressure injury that was not documented in medical records and the worsening of 3 pressure injuries that developed from MASD (moisture associated skin damage) into stage 2 (skin breaks down and forms a shallow ulcer into partial-thickness skin loss) and stage 3 (damage goes through the skin into the fat layer into full-thickness skin loss).Findings include:Review of R100s Hospital Discharge Documents dated… […]

• Actual harm, isolatedF757Jul 15, 2026

  Based on interview and record review, the facility failed to ensure comprehensive pain assessments were completed prior to the administration of opioid medications for three of three residents (Residents #1, #2, and #3) reviewed for unnecessary medications resulting in Resident #1 experiencing an opioid overdose requiring hospitalization and the use of intravenous (IV) drip administration of opioid reversal medications medications. without appropriate evaluation of pain characteristics, severity, or need placing residents at risk for adverse effects including oversedation, respiratory depression and ineffective pain management. […]