Inspection Reports for Medilodge of Grand Rapids

The inspection was conducted due to complaints and concerns regarding insufficient nursing staff to meet resident care needs, including delayed call light responses and inadequate assistance with transfers and hygiene.

The facility failed to provide sufficient nursing staff to meet resident needs, resulting in long wait times for call light responses, missed therapy sessions, and unmet care needs for multiple residents. Staffing shortages were confirmed by interviews with residents, staff, and family members, and were noted to cause frustration and discomfort among residents.

The complaint investigation found substantiated issues with staffing shortages leading to delayed call light responses (up to 50 minutes or more), missed therapy, and unmet resident care needs. Residents and family members reported frequent long waits for assistance. Staff interviews confirmed inadequate staffing levels and lack of management oversight. The Nursing Home Administrator acknowledged staffing absences and lack of a Quality Improvement Plan to address the issue.

The inspection was conducted as part of the annual survey of Medilodge of Grand Rapids to assess compliance with professional standards of quality, resident care, staffing, food safety, and mental health services.

The facility was found deficient in multiple areas including medication administration via feeding tubes, appropriate tube feeding care, insufficient nursing staffing, inadequate response to resident call lights, failure to provide appropriate mental health treatment and supervision for a resident with suicidal ideations, food safety violations in the kitchen, and ineffective quality assurance processes.

The inspection was conducted based on complaint intake #MI00148777 and related allegations concerning resident dignity, change in condition notification, wound care, fall prevention, staffing adequacy, and infection control.

The facility was found deficient in multiple areas including failure to preserve resident dignity, failure to notify family of change in condition resulting in delayed emergency transfer, failure to ensure physician orders for wound care and compression stockings, failure to implement treatment for acute stroke causing immediate jeopardy, inadequate supervision leading to falls with injury, insufficient staffing impacting resident care, and failure to properly implement infection prevention and control measures including PPE use and cleaning of shared equipment.

The complaint investigation was triggered by intake #MI00148777 involving allegations of failure to preserve resident dignity, failure to notify family of change in condition, inadequate wound care, failure to treat acute stroke, inadequate supervision leading to falls, insufficient staffing, and infection control deficiencies.

The inspection was conducted in response to a complaint alleging that Resident A was left unattended in the dining room on 12/21/2024 from 9:00 pm to 6:00 am and developed bed sores due to lack of staff assistance.

The investigation found no evidence to support the allegation that Resident A was left unattended or developed bed sores due to staff neglect. Interviews with the administrator and employees, observation of the facility, and documentation review revealed no violations.

Complaint alleged Resident A was left unattended in the dining room on 12/21/2024 from 9:00 pm to 6:00 am and had bed sores due to lack of staff assistance. The allegation was not substantiated; no violation was found.

The inspection was conducted due to a complaint intake MI00149223 regarding the facility's failure to report an incident of neglect involving a resident choking and subsequent death after receiving the wrong meal tray.

The facility failed to implement proper reporting procedures for an incident where Resident #100 was served the wrong diet tray, leading to choking and death. The investigation revealed inadequate supervision, failure to provide assistance during meals, and staff errors including a new employee delivering the wrong tray. Immediate jeopardy was identified and later removed after staff education and policy reinforcement.

Complaint intake MI00149223 involved Resident #100 choking and subsequent death due to receiving the wrong meal tray. The incident was not reported to the State Agency as required. Interviews revealed the facility staff, including the Administrator, did not consider the incident reportable. Immediate jeopardy was identified due to failure to provide correct diet and assistance, and was removed after corrective actions.

The investigation was initiated due to an anonymous complaint alleging neglect of Resident A and Resident B, as well as concerns about soiled linen and trash being kept in the shower room and shower leaks causing wet floors.

The investigation found no violations related to neglect of Resident A or Resident B, and no issues with shower leaks. However, violations were established for soiled linen and trash being stored in the shower room and for Resident B's service plan not being updated to reflect care needs accurately.

The complaint alleged Resident A was neglected by being left covered in urine for over an hour and staff turning off Resident A's call light without providing timely assistance. It also alleged Resident B was neglected by not receiving assistance with eating and being left in soiled briefs. Additional complaints included soiled linen and trash stored in the shower room and shower leaks causing wet floors. The investigation did not substantiate neglect allegations for Residents A and B but did substantiate the storage of soiled linen and trash in the shower room and the failure to update Resident B's service plan.

The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, safety, staffing, and facility conditions.

The facility was found deficient in multiple areas including resident dignity and privacy, unresolved resident grievances, inaccurate advanced directive documentation, inadequate access to linens, failure to provide routine showers, delayed lab services, insufficient staffing, improper respiratory care orders, inadequate food temperature and sanitation, and failure to maintain proper catheter and feeding tube care.

The inspection was conducted based on complaints and allegations related to resident privacy, resident rights, medication misappropriation, food palatability, infection control, and environmental cleanliness.

The facility was found deficient in respecting residents' privacy, accommodating resident choices, preventing medication misappropriation, providing palatable food, implementing infection prevention and control practices, and maintaining a safe, clean, and comfortable environment. Several residents reported dissatisfaction with food quality and privacy violations. Infection control practices were not consistently followed, and environmental cleanliness was inadequate in resident rooms and common areas.

The visit was complaint-related, triggered by multiple intakes including MI00143109, MI00143578, and MI00142857, involving allegations of privacy violations, medication misappropriation, food quality issues, infection control lapses, and environmental cleanliness concerns.

The document serves as a renewal notification for the Home for the Aged license of Medilodge of Grand Rapids, confirming substantial compliance with public health code and administrative rules over the past year.

An administrative review revealed substantial compliance with applicable public health codes and administrative rules regulating home for the aged facilities, resulting in the renewal of the facility's license for 12 months.

The inspection was conducted based on complaints and intake investigations regarding background checks, resident notifications, care plan accuracy, admission orders, quality of care, pressure ulcer prevention, staffing adequacy, medical record accuracy, and infection control.

The facility was cited for multiple deficiencies including failure to perform timely background checks and fingerprinting, failure to notify resident emergency contacts of transfers, failure to update care plans, inaccurate admission orders causing treatment delays, inadequate provision of ordered care, failure to perform timely skin assessments and pressure ulcer prevention, insufficient nursing staff leading to neglect, incomplete medical record documentation, and lapses in infection prevention practices such as hand hygiene and equipment sanitization.

The complaint investigation included intake numbers MI00140929, MI00139838, and MI00139892. Issues involved staff background checks, resident transfer notifications, care plan accuracy, admission orders, quality of care, pressure ulcer prevention, staffing adequacy, medical record accuracy, and infection control practices.

The investigation was initiated due to a complaint alleging that residents were not receiving their prescribed medications and that residents were served meals that were cold and late.

The investigation found no violation regarding medication administration, confirming that medications were administered as prescribed despite some delays. However, a violation was established regarding meal service, as meals were delivered on unheated open carts, causing them to be cold and served late to residents.

The complaint alleged that residents had not been getting their prescribed medications and that residents were served meals that were cold and late. The medication allegation was not substantiated, but the meal service allegation was substantiated.

The inspection was conducted due to a complaint regarding the facility's failure to ensure safety and prevent elopement of Resident #100, who exited the facility unnoticed, posing an immediate jeopardy to resident health and safety.

The facility failed to prevent elopement of Resident #100, a resident with severe cognitive impairment and known elopement risk, who exited the facility on 7/24/23 and was found outside near a busy road. Multiple prior attempts to exit were documented, and staff failed to provide adequate supervision or respond effectively to alarms. The facility implemented corrective actions including increased supervision, door alarm adjustments, staff education, and audits.

The visit was complaint-related due to a reported incident where Resident #100, assessed as an elopement risk, exited the facility unnoticed on 7/24/23 at approximately 7:30 PM and was found outside near a busy road. The complaint was substantiated with findings of inadequate supervision and alarm system failures.

The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication administration, infection control, and safety.

The facility was found deficient in multiple areas including failure to provide resident care per preferences, incomplete advance directive documentation, privacy violations during care, inadequate care planning, medication administration errors, failure to provide assistance with activities of daily living, improper wound care, pressure ulcer prevention deficiencies, inadequate range of motion services, unsafe resident transfers, oxygen therapy mismanagement, medication storage and labeling issues, food safety violations, inaccurate medical records, and infection control lapses.

The inspection was conducted based on multiple complaint intakes regarding failure to provide consistent assistance with activities of daily living, appropriate wound care, pressure ulcer prevention, and range of motion services.

The facility failed to consistently provide assistance with activities of daily living (bathing, incontinence care, eating) for several residents, resulting in potential negative outcomes. Additionally, the facility failed to provide appropriate wound care and pressure ulcer prevention for residents with wounds and pressure injuries. Range of motion services were also inconsistently provided for a resident with limited mobility.

This citation pertains to intake #'s MI00136297, MI00135104, MI00135459, MI00137661, and MI00137590. The complaints involved failure to provide adequate ADL assistance, wound care, pressure ulcer prevention, and range of motion services.

The inspection was conducted as a renewal licensing study for Medilodge of Grand Rapids to assess compliance with licensing requirements and determine if a regular license should be issued.

The facility was found to be in non-compliance with kitchen and dietary rules, specifically regarding uncovered salads in a refrigerator and the absence of reliable thermometers in mini refrigerators and freezers in resident rooms. Violations were established for both issues.

The inspection was conducted due to complaints regarding failure to provide timely pain medication to residents and inadequate care and monitoring of nephrostomy tubes, resulting in harm to residents.

The facility failed to dispense pain medication in a timely manner for one resident, resulting in increased pain and hospitalization. Additionally, the facility failed to monitor and care for nephrostomy tubes according to professional standards, leading to immediate jeopardy and emergency hospitalization of another resident. The facility lacked policies for controlled substance management and nephrostomy care, and staff education and competency were inadequate.

The complaint investigation revealed substantiated issues including delayed pain medication administration for resident #16 and inadequate nephrostomy tube care for resident #10, resulting in actual harm and immediate jeopardy respectively.

The inspection was conducted due to complaints regarding failure to provide timely pain medication to residents and inadequate care and monitoring of nephrostomy tubes, resulting in harm to residents.

The facility failed to dispense pain medication in a timely manner for one resident, resulting in increased pain and hospitalization. Additionally, the facility failed to properly monitor and care for nephrostomy tubes for another resident, leading to immediate jeopardy due to serious infection and emergency hospital transfer.

The complaint investigation revealed that resident #16 did not receive pain medication as ordered, causing increased pain and hospitalization. Resident #10's nephrostomy tubes were not properly cared for, leading to infection, dislodgement, and emergency hospital transfer. Immediate Jeopardy was identified but later removed after corrective actions.

The investigation was initiated due to complaints alleging the facility was short staffed and that meals were served cold and not at regular mealtimes.

The investigation found no violation regarding staffing adequacy, as the facility had systems in place to cover shifts despite call-ins. However, a violation was established for meals being served late and cold due to multiple kitchen staff call-ins. Additionally, a violation was found for failure to update the facility administrator records after a change in administration.

The complaint alleged the facility was short staffed and meals were served cold and not at regular mealtimes. The short staffing allegation was not substantiated, but the meal service allegation was substantiated.

The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Medilodge of Grand Rapids.

The facility was found to be in full compliance with applicable licensing acts and administrative rules. A temporary license with a maximum capacity of 103 residents was recommended for issuance.