Medilodge Of Southfield
Medilodge of Southfield in Southfield, MI — inspection on August 15, 2025.
Found 17 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-08-15.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0558 during a standard health inspection conducted on 2025-08-15.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Assure the security of all personal funds of residents deposited with the facility.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #1194668.Based on record review and interview, the facility failed to purchase a surety bond in an amount equal to the current balance of personal funds held in the resident trust fund.
This deficient practice has the potential to affect 82 resident's that have funds managed by the facility.
Findings include:On [DATE] at 2:24 PM, the facility was requested to provide a list of residents that have personal funds managed by the facility (resident trust fund), and the facility's surety bond (an agreement between the principal [the facility], the surety [the insurance company], and the oblige [either the resident or the State acting on behalf of the resident], wherein the facility and the insurance company agree to compensate the resident (or the State on behalf of the resident) for any loss of residents' funds that the facility holds, safeguards, manages, and accounts for).
Review of the documentation provided revealed the provided list of residents that had current balances as of [DATE] included Total Accounts: 82 .Current balance $63,240.36 .The facility's surety bond which was dated [DATE] - [DATE] documented it was only for $45,000.00.On [DATE] at 8:32 AM, an interview was conducted with the Business Office Manager (Staff ‘H‘) who reported they had been in their role for about a year.
When asked about the residents included on the documentation that had money in the facility's resident trust fund, Staff ‘H' confirmed there was at least one resident that had expired [DATE] but was still showing as having funds.
They reported they were not sure why that happened and would follow-up.
When asked about the surety bond amount which was much lower than the current balance for [DATE], Staff ‘H' reported they would follow-up.On [DATE] at 10:40 AM, Staff ‘H' provided additional documentation and reported the trust fund balances from previous months were lower than $45,000 and further reported they had not processed the patient pay amounts for the month of August yet, so it would be lower amount that what it was showing.
Staff ‘H' was asked if there was a specific date the resident's patient pay amounts were removed for payment and they indicated there was not, and it varied.
They were informed the current surety bond provided did not cover the current balance and remained a concern.On [DATE] at 1:15 PM, Staff ‘H' reported the facility's trust fund balance documentation of previous months were under $45,000 and they were still waiting to process patient pay amounts for the month.
When asked if that usually occurs on a specific date, Staff ‘H' stated the dates varied for multiple residents.
Staff ‘H' was informed the concern remained since the current balance of the resident trust fund was significantly higher than the amount of the surety bond.On [DATE] at 9:44 AM, the facility was requested to provide a policy regarding the surety bond. At 9:59 AM, the Administrator reported they did not have a policy regarding surety bond.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Medilodge of Southfield
26715 Greenfield Rd Southfield, MI 48076
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0585 during a standard health inspection conducted on 2025-08-15.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
queried regarding the mostly blank discharge forms for both R172 and R173 and the lack of clinical information that was provided up on discharge and they indicated that they did identify the same issue around that time with facility staff failing to complete the discharge form, SWD C reported that each discipline in the facility should have filled out their sections completely. On 8/13/25 a facility document titled Discharge Planning Process was reviewed and revealed the following: Policy: It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions 1.
Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary will be provided to the receiving care provider.
The Discharge Summary should include a. An overview of the resident's stay that includes but not limited to: diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results' b. A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. c.
Reconciliation of all pre-discharge medications with the resident's post discharge medication to include prescription and over the counter medications
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Medilodge of Southfield
26715 Greenfield Rd Southfield, MI 48076
SUMMARY STATEMENT OF DEFICIENCIES
According to the facility's policy titled, Activities of Daily Living (ADLs) dated 12/28/2023: .A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Medilodge of Southfield
26715 Greenfield Rd Southfield, MI 48076
SUMMARY STATEMENT OF DEFICIENCIES
Review of a facility policy titled, “Notification of Changes” revised [DATE] read in part, “…Circumstances requiring notification include: 1.
Accidents… 2.
Significant change in the resident’s physical, mental, or psychosocial conditions such as deterioration in health, mental or psychosocial status… 3.
Circumstances that require a need to alter treatment… 4. A transfer or discharge of the resident from the facility…” The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the immediacy.
The facility assessed current residents for a change in condition by reviewing labs and vital signs.
Education was provided to nursing staff on assessment, notifying the physician and implementing orders and documentation.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Medilodge of Southfield
26715 Greenfield Rd Southfield, MI 48076
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
resident wanted a specific lift (this was not identified in the resident's clinical record - in progress notes, care plans, or social service assessments). SSD ‘C' reviewed the documentation available for R138 and confirmed there was no other details included as to what facilities had been attempted, or any other specifics details. SSD ‘C' reported they would follow-up with Staff ‘D', however there was no further follow-up or documentation provided by the end of the survey.According to the facility's policy titled, Discharge Planning Process dated 10/20/2023: .The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge .The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community .The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities .The facility will assist residents and their resident representatives in choosing an appropriate post-acute care provider (i.e. another SNF .that will meet the resident's needs, goals and preferences .The Social Services Director, or designee, shall compile available data as needed on other post-acute care options to present to the resident, including, but not limited to .Data on providers within the resident's desired geographic areas, where available .
Facility ID:
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-15.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0791 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide or obtain dental services for each resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0804 during a standard health inspection conducted on 2025-08-15.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-15.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0865 during a standard health inspection conducted on 2025-08-15.
Category: Administration Deficiencies
The facility was found deficient in the following area: Have a plan that describes the process for conducting QAPI and QAA activities.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Federal health inspectors cited Medilodge of Southfield in Southfield, MI for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-15.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of Medilodge of Southfield.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.