Medilodge of Traverse City

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 20, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with fracture for one Resident (R19) of five residents reviewed for falls. This deficient practice resulted a tibial (lower leg) fracture, with increased pain. Findings include: Review of R19's Minimum Data Set (MDS) assessment, dated 11/15/23, revealed R19 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and depression. R19 required assistance with toileting and was independent with transfers and walking. R19 was unable to participate in the Brief Interview for Mental Status (BIMS) assessment, showing severe cognitive impairment. The sensory assessment revealed R19 was sometimes understood, and sometimes able to understand. […]

• Actual harm, isolatedF692Apr 3, 2023

  Based on interview and record review, the facility failed to ensure adequate monitoring of a high risk resident (Resident #66) for inadequate intake of foods and fluids during a COVID infection. This deficient practice resulted in Resident #66 having an acute change in condition requiring hospitalization where she was found with acute dehydration and septic shock and expired seven days after readmission to the facility. Finding include: Resident #66 (R66): A review of R66's medical record revealed she admitted to the facility on [DATE] with diagnoses including quadriplegic cerebral palsy, dysphagia, hx (history) of sepsis, and dementia. […]

• Actual harm, isolatedF689Mar 17, 2023

  This citation pertains to intake MI00132096 Based on observation, interview and record review, the facility failed to prevent a fall with major injury for one Resident (#308) of four residents reviewed for falls. This deficient practice resulted in a laceration to the right forehead above the eyebrow requiring sutures, surgical intervention for a fracture of the left tibia, and a subsequent required hospital stay. Findings include: A review of the Electronic Medical Record for Resident #308 revealed an initial admitted to the facility on [DATE] with diagnoses including repeated falls, cognitive social or emotional deficit following cerebral infarction, weakness, cerebral infarction (Stroke 8/24/22), Dysphagia (difficulty swallowing 8/24/22), muscle weakness, abnormalities of gait and… […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2024

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in a food borne illness among any and all 58 residents. Findings include: On 3/18/24 at approximately 10:30 AM, a bag of food was observed in the upright refrigerator in the kitchen. The bag was from a local fast food restaurant and labeled with a resident's name. An interview with conducted with Kitchen Manager (KM) A at this time and it was learned the bag was brought into the facility by the resident's family member, accepted by kitchen staff and stored in the refrigerator. The bag contained breakfast sandwiches according to KM A. […]

• No harm, potential for more than minimal, widespreadF732Dec 20, 2023

  Based on observation, interview, and record review, the facility failed to post accurate staffing information for Certified Nurse Aides (CNA) directly responsible for resident care per shift. This deficient practice had the potential to affect all 57 residents in the facility and resulted in the potential inability of residents and visitors to determine the number of staff available to provide resident care. Findings include: On 12/20/23 at 10:00 a.m., the Nursing Home Administrator (NHA) was questioned regarding the location of the posting for staffing information. The NHA indicated the information was posted near the nurses' station on B Hall. The posting was a form labeled, Daily Staffing for Wednesday December 20, 2023 and was reviewed with the NHA present. […]