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Complaint Investigation

Medilodge Of Howell

Inspection Date: September 11, 2025
Total Violations 1
Facility ID 235331
Location Howell, MI
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Inspection Findings

F-Tag F0684

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2600758Based on interview and record review the facility failed to ensure timely administration of an ordered and requested pain medication (Oxycodone) for one resident (Resident R101) of one reviewed for pain. Findings include:Findings include:Clinical record review revealed Resident R101 sustained trauma resulting in necrotizing fasciitis (also known as flesh-eating disease, an infection that kills the body's soft tissue) of the left upper extremity and lower extremity. Resident R101 underwent emergent debridement (surgical procedure that involves the removal of dead, damaged, or infected tissue) and fasciotomy (surgical procedure involves cutting through the tissues that surround muscles) of the left anterior (front) thigh and left forearm, underwent multiple debridement's, left femoral muscle flap graft and required a Wound VAC (vacuum-assisted closure technique that pulls tissue of a wound together and promotes healing). Resident R101's pain regimen included Oxycodone 10 milligram (mg) every four hours as needed, and hospital discharge paperwork confirmed the last time Resident R101 had received Oxycodone 10 mg was on 8/14/25 at 10:00 AM.On 9/10/25 around 2:30 PM, a telephone interview with the complainant confirmed their allegations and stated Resident R101 was admitted on [DATE REDACTED] around 3:30 PM for further skilled nursing care and rehabilitation. Resident R101's pain regimen included Oxycodone 10 mg every four hours and was still requiring every four hours for pain control. On 8/14/25 Resident R101 had requested to the admission Nurse they needed Oxycodone. The Nurse assured them Oxycodone was ordered, and until it was filled and received from the Pharmacy, they (Nursing) can pull the medication from a back up supply. On 8/14/25 at approximately 4:00 PM Resident R101 had requested ordered Oxycodone. On 8/14/25 at 9:00 PM, Resident R101 still had not received and requested Oxycodone. Nursing remarked everything was all set and would be provided. The complainant then received a phone call from Nursing around 11:00 PM and when they asked if Resident R101 had received their Oxycodone, Nursing reassured pain medication was given. The complainant arrived at the facility on 8/15/25 around 2:00 PM, Resident R101 informed me that more requests were made for Oxycodone, and no Oxycodone was administered.Record review of the Medication Administration Record (MAR) documented

an order for Oxycodone 10 mg by mouth every four hours as needed for Pain. Start Date 08/14/2025 at 17:15. No Oxycodone was documented as administered on 8/14/25.Record Review of the Provider Encounter on 8/15/25 documented .Situation: Need OXY 5 mg 2 pills as a now dose-out of 10 mg tablets Treatment: ordered Oxycodone 5 mg take two pills x 1 dose .On 9/10/25 The Director of Nursing (DON) provided Resident R101's Control Substance Record and documentation revealed Resident R101 did not receive Oxycodone 10 mg as ordered starting on 8/14/25. Documentation revealed Resident R101 had not received the Oxycodone ordered until 8/15/25 at 21:00. The DON acknowledged the medication was never provided to R101as ordered.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

πŸ“‹ Inspection Summary

Medilodge of Howell in Howell, MI inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Howell, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Medilodge of Howell or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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