Medilodge of Leelanau

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 26, 2026

  This deficient practice pertains to Intake #3158817.Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in a fall with injuries for one Resident (#2) of three residents reviewed for accident hazards and supervision. This deficient practice resulted in facial lacerations and broken dentition for Resident #2.Findings include:Resident #2 (R2)Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/20/23 with diagnoses including dementia, Alzheimer's disease, and a cognitive communication deficit. […]

• Actual harm, isolatedF686Sep 14, 2021

  Based on observation, interview, and record review, the facility failed to provide necessary treatment and services consistent with professional standards of practice, to prevent new pressure ulcers from developing for one Residents (#31) of four residents reviewed for pressure ulcers. This deficient practice resulted in harm to Resident #31 with the development of three new pressure injuries, delayed healing with lack of pressure injury prevention interventions, and increased pain. Findings include: Review of Resident #31's medical record revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was noted to need two person assist with activities of daily living and used a wheelchair for ambulation. […]

• Actual harm, isolatedF689Sep 14, 2021

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to assure resident safety during a transport for one Resident (#31) of six residents reviewed for safety. This deficiency practice resulted in Resident #31 unbuckling her seatbelt causing her to fall and sustain a right tibia and fibula fracture and the potential for other residents using the facility transportation service to be not adequately supervised. Findings include: Review of Resident #31's Face Sheet revealed admission to the facility on [DATE] with diagnoses including: Cerebral infarct (infarct is also known as a stroke), [CONDITION(S)] disease, hypertension, [CONDITION(S)], and [CONDITION(S)] and [CONDITION(S)] following other [CONDITION(S)] disease affecting right dominant… […]

• No harm, potential for more than minimal, widespreadF725Dec 11, 2024

  This deficiency pertains to Intake MI00147043 Based on observation, interview, and record review, the facility failed to maintain sufficient staff for four (Resident #8, #37, #41, and #63) of seventeen residents reviewed for staffing. Findings include: Resident #37 (R37) An interview was conducted on 12/9/24 at 12:13 PM with R37, who stated the quality of care has gone down since last year. R37 stated they constantly witnessed one nurse taking care of half the building. One nurse for both Orchard and Wharf, and one nurse for Cabin and Cedar. R37 stated the facility never really has four nurses at the same time and stated that it seemed there were a lot of call ins from the Certified Nursing Aides (CNAs) and it screws everything up. […]

• No harm, potential for more than minimal, widespreadF838Dec 11, 2024

  Based on interview and record review, the facility failed to conduct and document an annual facility wide assessment resulting in the potential for inadequate resources to meet the needs and care for all 68 facility residents. On 12/9/24 during the entrance conference at 11:50 AM the Nursing Home Administrator (NHA) was asked for a copy of the Facility Assessment. The NHA provided a Facility Assessment Tool for 7/2023 through 6/2024. The NHA was asked if there were any updates to the facility assessment to meet the requirement of being reviewed and updated annually. During a follow-up interview on 12/10/24 at 3:20 PM, the NHA stated all files provided were the most current. […]