Medilodge Of Grand Blanc

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

other alternatives have been tried unsuccessfully. Policy Explanation and Compliance Guidelines: Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). An evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom.II. Side Rails Policy date reviewed/revised 10/26/23Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of side rails. Alternative approaches are attempted prior to installing a side or bed rail. If used, the facility ensures correct installation, use, and maintenance of the rails.The facility's definition of:Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:a. Is attached or adjacent to the resident's body;b. Cannot be removed easily by the resident; andc. Restricts the resident's freedom of movement or normal access to his/her bodyThe Policy Explanation and Compliance Guidelines:.c. Obtain informed consent from the resident or the resident's representative for the use of bed rails before installation/use.d.

Determine whether or not the side/bed rail is a restraint. Side/bed rails will be considered a physical restraint when they limit the resident's freedom of movement and cannot be removed easily by the resident.

In such cases, the facility shall follow procedures related to physical restraints.e. Document the medical diagnosis, condition, symptom, or functional reason for the use of the side/bed rail.f. Obtain physician orders for the use of side/bed rails . 4. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes:a. Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible.b. Ensuring that the bed's dimensions are appropriate for the resident.c. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed.d. Installing bed rails using the manufacturer's instructions to ensure a proper fit.e. Inspecting and regularly checking the mattress and bed rails for gaps and areas of possible entrapment.f. Checking rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time.5. The use of side rails will be specified in the resident's plan of care.a. Side rails that are permanently installed on

the bed frame shall not be used, even incidentally, without proper assessment, informed consent, and physician orders.b. Once side/bed rails are installed, the facility will ensure side rail/bed rail usage does notprohibit necessary treatments and resident care. Care and treatments will continue to beprovided in accordance with professional standards of practice and resident choices.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Blanc

11941 Belsay Road Grand Blanc, MI 48439

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Nurse “F” agreed that Resident R104 had both a PICC and a tube feeding recently discontinued, and that Resident R104 currently had an indwelling urinary catheter and infected wounds. Nurse “F” further agreed Resident R104 was highly susceptible to transmission of pathogens.

Nurse “F” points out an EBP personal protection equipment (PPE) drawer unit that is inside Resident R104's room. The PPE drawer unit she pointed out was in front of Resident R104's roommates' bed and the

observation of contents revealed it had scant PPE in it, consisting of only a couple of gowns.

On 09/11/2025 ~2 PM, During interview with DON she confirmed that residents in precautions will have sign indicating the type of precautions (enhanced, contact etc.…) needed outside the residents' room doors to alert staff, family and visitors.

A record review of facility progress notes dated 08/22/2025 stated, “Resident recently hospitalized for declining wound. Patient presented to the hospital with worsening wounds of the sacrum and lower back. Patient has a history of chronic sacral ulcer which has been treated at our facility stage IV. Patient was also having cellulitis of the thoracic spine there was a concern for necrotizing fasciitis. Patient had a debridement done on August 15, 2025 by surgery. Patient was seen by infectious disease placed on IV antibiotics. Patient was subsequently stabilized and transferred back to our facility. Patient continues to be

on IV antibiotics…”.

A record review of Resident R104's medical chart there was an order dated 08/21/2025 that read: “Use enhanced barriers while performing high-contact activity with the resident. PEG – Wound”.

A record review of Resident R104's physician and pharmacy section there was an order dated 09/04/2025 that read, “Cipro Oral Tablet 500 MG Give 1 tablet by mouth every 12 hours for Wound infection for 14 Days give with meals. Amoxicillin-Pot Clavulanate 875-125 MG Tablet Give 1 tablet by mouth every 12 hours for Wound infection for 14 Days give with meals”.

A record review of Resident R104's care plan revealed, Interventions: Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray. Date Initiated: 03/14/2025; Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis) Date Initiated: 03/14/2025; Review with visitors and family members how to follow the recommended precautions when visiting if prolonged physical contact is anticipated Date Initiated: 03/14/2025”.

According to a record review of the facility's Policy & Procedure labeled infection control plan revealed, Isolation signs are used to alert staff, family members and visitors of transmission-based precautions”. According to the facility's policy on Enhanced Barrier Precautions: “Enhanced barrier precautions refer to an infection control intervention designed to reduce the transmission of Multidrug-resistant organisms that employs targeted gown, and gloves use during high-contact resident care activities” and “Initiation of enhanced barrier precautions… iii. Infection colonized with a CDC-targeted MDRO when contact precautions do not apply”.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet