Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Medilodge of Mt. Pleasant.
Findings
The facility was found deficient in several areas including failure to ensure call lights were accessible to residents, failure to notify a resident's representative of a fall with injury, failure to implement care planned fall interventions, improper labeling of tube feeding, failure to provide ordered nebulizer treatments and clean equipment, inaccurate narcotic administration documentation, unsafe food handling practices in the kitchen, and lack of an active plan for reducing risk of legionella and other opportunistic pathogens in the plumbing system.
Deficiencies (8)
Failed to ensure call lights were in reach for 2 dependent residents.
Failed to notify the resident's representative of a fall with injury for 1 resident.
Failed to implement care planned fall interventions for 1 resident.
Failed to correctly label an ordered tube feeding for 1 resident.
Failed to offer ordered nebulizer treatments and adequately clean nebulizer equipment for 1 resident.
Failed to accurately document narcotic administration for 1 resident.
Failed to maintain best practices in the kitchen, including improper use of handwashing sink and lack of air gap on ice machine drain line.
Failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens in premise plumbing.
Report Facts
Residents reviewed for call light availability: 4
Residents reviewed for falls: 2
Residents reviewed for tube feeding: 3
Residents reviewed for respiratory care: 2
Residents reviewed for pharmacy services: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant C | Certified Nursing Assistant | Reported on call light use for residents R5 and R20 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding fall notification and care plan implementation |
| Unit Manager/Registered Nurse N | Unit Manager/Registered Nurse | Interviewed regarding tube feeding labeling expectations |
| Registered Nurse D | Registered Nurse | Interviewed regarding narcotic administration documentation |
| Registered Nurse I | Registered Nurse | Interviewed regarding importance of narcotic documentation |
| Dietary Manager K | Certified Dietary Manager | Interviewed regarding kitchen practices |
| Dietary H | Dietary Staff | Observed filling water pitchers from hand sink |
| Maintenance Director F | Maintenance Director | Interviewed regarding plumbing and flushing schedule |
| Maintenance Director B | Maintenance Director | Interviewed regarding plumbing and flushing schedule |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 28, 2024
Visit Reason
The inspection was conducted to assess compliance with safety, care, infection control, and immunization regulations in the nursing home.
Findings
The facility failed to provide adequate smoking supervision and monitoring for 5 residents, failed to properly assess and administer feeding tube care for 1 resident, failed to implement proper infection prevention and control precautions for 3 residents, and failed to administer pneumococcal and influenza vaccinations to 1 resident.
Deficiencies (4)
Failed to provide adequate smoking supervision and monitoring for 5 of 14 residents, including failure to ensure oxygen safety, secure smoking materials, and proper supervision during smoking.
Failed to assess, monitor, and care for a resident receiving tube feedings per facility policy and professional standards of care.
Failed to ensure Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) were in place and followed for 3 residents, increasing risk of infection spread.
Failed to administer pneumococcal and influenza vaccination to 1 resident, despite consent from the resident's power of attorney.
Report Facts
Residents reviewed for smoking supervision: 14
Residents affected by smoking supervision deficiency: 5
Residents reviewed for feeding tube care: 3
Residents affected by feeding tube care deficiency: 1
Residents reviewed for infection precautions: 4
Residents affected by infection control deficiency: 3
Residents reviewed for immunizations: 5
Residents affected by immunization deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN H | Registered Nurse | Observed administering medication via peg tube incorrectly. |
| RN S | Registered Nurse | Reported proper procedure for feeding tube medication administration. |
| RN K | Registered Nurse | Reported proper procedure for feeding tube medication administration and observed filling graduated cylinder from shared bathroom. |
| RN J | Registered Nurse | Reported proper procedure for feeding tube medication administration. |
| DON | Director of Nursing | Reported expectations for feeding tube medication administration and infection control education. |
| Scheduler Q | Reported staff procedures for smoking paraphernalia and sign-out requirements. | |
| Corporate Nurse R | Reported staff procedures for smoking paraphernalia and feeding tube medication administration. | |
| NHA | Nursing Home Administrator | Confirmed smoking evaluations and guardian consent for smoking. |
| RN Unit Manager D | Registered Nurse Unit Manager | Reported lack of physician orders for Enhanced Barrier Precautions and reviewed resident records. |
| CNA C | Certified Nursing Assistant | Reported education on hand hygiene for C-diff precautions. |
| Housekeeping Supervisor P | Reported awareness of residents in isolation. | |
| Laundry Staff M | Reported resident isolation status. | |
| Certified Nursing Assistant I | Certified Nursing Assistant | Reported resident isolation status. |
| Unit Manager N | Reported resident isolation status. | |
| Housekeeping Staff L | Reported cleaning procedures following C-diff testing. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent the development and worsening of pressure ulcers for one resident (Resident #5).
Complaint Details
The complaint investigation found that Resident #5 developed unstageable pressure ulcers related to prolonged exposure to a bedpan or commode. The wounds were first documented on 10/2/23 but were not properly assessed or treated promptly. Interviews revealed staff concerns about the wounds but lack of timely action. The Director of Nursing was unaware of the wound treatment details and did not investigate the cause. The care plan lacked interventions specific to the suspected etiology of the pressure ulcers.
Findings
The facility failed to prevent pressure ulcers from developing and worsening in Resident #5, who had multiple risk factors and was found to have unstageable pressure ulcers likely related to prolonged use of a bedpan or commode. Documentation and treatment orders were delayed or incomplete, and care plan interventions did not address the suspected causes of the ulcers.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #5.
Report Facts
Residents reviewed for pressure ulcers: 2
Wound size: 14.79
Wound dimensions: 8.63
Wound dimensions: 2.55
Skin abrasion dimensions: 11
Skin abrasion dimensions: 5
Skin abrasion dimensions: 2.5
Skin abrasion dimensions: 2.5
Skin abrasion dimensions: 1.5
Skin abrasion dimensions: 1
Skin abrasion dimensions: 11
Skin abrasion dimensions: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Documented skin assessment and reported concerns about Resident #5's wounds |
| RN F | Unit Manager/Wound Care Nurse | Evaluated wounds, instructed documentation, provided wound care, and interviewed regarding wound observations |
| RN U | Registered Nurse | Completed Other Skin incident report and assessed Resident #5's wounds |
| CNA T | Certified Nurse Aide | Provided witness statement and reported observations of Resident #5's skin issues |
| NP V | Nurse Practitioner | Conducted nursing home visits, reviewed labs, and provided clinical notes on Resident #5 |
| DON | Director of Nursing | Assessed wounds, reviewed EMR, and interviewed regarding wound documentation and investigation |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 25, 2023
Visit Reason
The inspection was conducted to assess compliance with medication administration orders and food safety standards in the facility.
Findings
The facility failed to ensure medications were administered according to doctor's orders for two residents, resulting in medication given outside prescribed parameters. Additionally, the kitchen had plumbing issues and failed to properly cool potentially hazardous foods, risking contamination.
Deficiencies (2)
Failure to follow doctor's orders for medication administration for two residents, resulting in medication given outside parameters.
Failure to maintain kitchen plumbing and properly cool potentially hazardous food, risking contamination.
Report Facts
Medication administered outside parameters: 47
Medication held as ordered: 15
Medication administered outside parameters: 18
Units of insulin administered: 75
Blood sugar level: 122
Temperature of cream of wheat: 112
Temperature of sausage gravy: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician A | Physician | Interviewed regarding expectation that nurses follow doctor's orders |
| Director of Nursing | Director of Nursing (DON) | Acknowledged medication administration outside parameters and described EMR alert system |
| Registered Nurse C | Registered Nurse | Reported administering insulin to Resident #13 and rationale for timing |
| Certified Dietary Manager U | Certified Dietary Manager | Interviewed about kitchen plumbing issues and food cooling practices |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, food safety, and facility maintenance at Medilodge of Mt. Pleasant.
Findings
The facility failed to ensure proper adherence to doctor's orders for medication administration for two residents, resulting in medications given outside prescribed parameters. Additionally, the kitchen had plumbing leaks and improper cooling of potentially hazardous foods, posing contamination risks.
Deficiencies (2)
Failure to follow doctor's orders for medication administration for two residents, resulting in medication given outside parameters.
Failure to maintain kitchen plumbing and properly cool potentially hazardous food, risking contamination.
Report Facts
Medication administrations outside parameters: 47
Medication administrations held: 15
Medication administrations outside parameters: 18
Insulin dose: 75
Blood sugar level: 122
Temperature: 112
Temperature: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician A | Interviewed regarding expectations for nurses to follow doctor's orders | |
| Director of Nursing | DON | Acknowledged medication administration outside parameters and described EMR alert system |
| Registered Nurse C | RN | Administered insulin to Resident #13 and provided explanation for timing |
| Certified Dietary Manager U | CDM | Interviewed about kitchen plumbing issues and food cooling practices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving a resident (R3) where the facility allegedly failed to follow the resident's care plan for toileting assistance.
Complaint Details
The complaint investigation found that CNA C did not follow R3's care plan requiring two-person assistance for transfers and toileting, transferring R3 alone which led to a fall and injuries. The resident denied ever stating she needed only one-person assistance. The Director of Nursing stated only one-on-one education was provided to CNA C and plans to educate all staff on transfer protocols.
Findings
The facility failed to prevent a fall by not following the care plan requiring two-person assistance for transfers and toileting for resident R3, resulting in R3 falling and sustaining two skin tears. Staff education was provided to the involved CNA, and the Director of Nursing acknowledged the need for broader staff education on transfer protocols.
Deficiencies (1)
Failure to prevent a fall by not following a resident's care plan for toileting assistance, resulting in injury.
Report Facts
Skin tear size: 1.5
Skin tear size: 1
Skin tear size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in the finding for not following resident R3's care plan for transfers and toileting |
| CNA R | Certified Nursing Assistant | Interviewed regarding transfer procedures and resident assistance |
| Director of Nursing | Director of Nursing | Provided statements about staff education and fall intervention |
Viewing
Loading inspection reports...
