Medilodge of Sault Ste. Marie

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 30, 2024

  This deficiency pertains to Facility Reported Incident (FRI) MI00145815. Based on observation, interview, and record review, the facility failed to prevent, detect, and respond to an elopement resulting in the likelihood of serious harm, injury, impairment, or death for two Residents #4 and #5 (R4, R5) of three residents reviewed for elopement. Findings Include: The Immediate Jeopardy began on 7/13/24 at 6:18 PM when R4 and R5 eloped from the facility undetected and whose location was subsequently identified and reported to be on a thoroughfare by a facility visitor. Regional Director of Operations F was notified of the immediate jeopardy on 7/25/24 at 4:27 PM. At that time, a written plan of correction for removal was requested from the facility. […]

• Immediate jeopardy, isolatedF689Jan 29, 2024

  This Deficient Practice Statement (DPS) has two parts: A and B. DPS A: This deficiency pertains to Facility Reported Incident (FRI) MI00142212. Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in an elopement with the likely serious harm, injury, impairment or death for one Resident (#49) of one resident reviewed for accidents/hazards. Findings Include: The Immediate Jeopardy began on 1/10/24 at 7:23AM when R49 was observed ambulating northbound in a southbound lane by an employee (Staff V) driving into work. Regional Senior Administrator GG was notified of the immediate jeopardy on 1/23/24 at 4:40PM. At that time, a written plan of correction for removal was requested from the facility. […]

• Actual harm, patternF725Feb 11, 2026

  This citation pertains to Intake 2702621.Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the highest possible level of physical, mental, and psychological well-being for all 86 residents of the facility as evidenced by:Failure to ensure assistance with activities of daily living (ADLs) including routine incontinence care, bathing, shaving, turning and repositioning, and feeding.Failure to accommodate resident preferences including sleep/wake schedules, treatment times, and physical location within the facility.Failure to ensure a timely, dignified, and palatable meal service.Failure to maintain a restorative therapy program.Failure to respond to call lights within an appropriate time frame.These deficient practices resulted in… […]

• Actual harm, isolatedF600Feb 11, 2026

  This citation pertains to intake 2702621Based on observation, interview, and record review the facility failed to provide routine incontinence care for one Resident #4 (R4) of two residents reviewed for incontinence care. This deficient practice resulted in harm including anger, frustration, helplessness, and sadness based on the reasonable person concept.Findings include: On 2/8/2026 at 1:55 PM a foul odor was noted while standing near the doorway of R4's room and R4 could be heard calling out Nurse? Nurse? Upon entering R4's room, R4 was observed lying in a fetal position in bed with her bottom sheet pulled off the mattress and gathered around her and a top sheet draped over her torso and lower body. Upon approaching the bed, an overpowering smell of urine and feces was noted. […]

• Actual harm, isolatedF686Feb 4, 2026

  This citation pertains to intake 2720794.Based in observation, interview and record review, the facility failed to implement timely interventions to prevent the development and worsening of pressure ulcers for two Residents (#10 and (#14) of three residents reviewed. This deficient practice resulted in R10 developing an unstageable (a severe, full-thickness wound covered with necrotic tissue covering the wound bed causing inability to determine true wound depth) requiring surgical debridement (surgical removal of dead tissue), intravenous (IV) antibiotic therapy and hospitalization.Findings include:Resident #10 (R10)Review of a confidential complaint submitted to the State Agency (SA) on 1/12/2026 at 12:25 p.m. […]