Medilodge Of Gtc

F 0627 Level of Harm - Actual harm Residents Affected - Few

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

days. Today is day 13. New Follow Up Note on 10/6/25 at 9:32 PM by NP C: 10/4 - Surgical site midline abdomen still has staples, with skin healing around staples and patient reports wanting to scratch. New Follow Up Note on 10/6/25 at 9:32 PM by NP C: 10/6- Discharge planned for later this afternoon.Patient still needs post-op follow up and staple removal from abdominal incision.On 10/22/25 at 1:17 PM, an interview was conducted with the Nursing Home Administrator (NHA) who stated it is expected the facility coordinates and schedules all follow-up appointments.Review of the facility policy titled, Transfer and Discharge (including AMA [against medical advice]), revised 10/30/23, read, in part: .the facility permits each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered.

Event ID:

Facility ID:

If continuation sheet

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

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Gtc

2950 Lafranier Road Traverse City, MI 49686

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 0684 Level of Harm - Minimal harm or potential for actual harm

for orders a. Milk of magnesia 30ml PRN (as needed) for no BM x 3 days b. Bisacodyl 1 suppository PR (per rectum) PRN if Milk of magnesia is ineffective c. Fleets enema 1 application PRN if Bisacodyl is ineffective 5) Administer medication and monitor for effectiveness 6) Notify physician if bowel protocol is ineffective.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Gtc

2950 Lafranier Road Traverse City, MI 49686

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 - Actual harm Residents Affected - Some

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

had an extensive rash on her chest and arms which required treatment. Resident R3 stated the rash, itched terribly and remained, though not as bad.Resident #4 (Resident R4)Review of Resident R4's EMR revealed a Progress Note, dated 10/14/25 at 8:00 AM, which read, in part: .Resident exposed to confirmed scabies case; presenting with pruritic rash consistent with scabies infestation.Resident #5 (Resident R5)Review of Resident R5's EMR revealed a Progress Note, dated 10/14/25 at 8:00 AM, which read, in part: .Resident exposed to confirmed scabies case; presenting with pruritic rash consistent with scabies infestation.Resident #6 (Resident R6)Review of Resident R6's EMR revealed the following entries:Progress Note, 10/16/25 at 8:00 AM: .Chief complaint: rash is spreading. Pt [patient] seen for the above hydrocortisone was ineffective, the rash has spread to his opposite arm and down his abdomen. He complains of severe itch, especially at night. Suspect scabies, recent in outbreak in facility.New Follow Up Note, 10/23/25 at 1:06 PM: .he states he is only uncomfortable due to his full body rash. 10/14: Pt presented with raised red rash on BLE (bilateral lower extremities) and chest over the weekend.Pt reports feeling itchy and uncomfortable.Resident #7 (Resident R7)Review of Resident R7's EMR revealed a Progress Note, dated 10/14/25 at 8:00 AM, which read, in part: .exposed to confirmed scabies case; presenting with pruritic rash consistent with scabies infestation.On 10/24/25 at 9:24 AM, a follow-up

interview was conducted with the DON who understood the concern regarding the lack of implementation of infection control measures after Resident R2's scabies diagnosis in September 2025 and the current scabies infestation.Review of the facility policy titled, Infection Prevention and Control Program, revised 10/24/22, read, in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents.A review of the CDC guidelines titled, Public Health Strategies for Scabies Outbreaks in Institutional Settings, dated 12/18/23, read, in part: Prevention: Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent. Establish surveillance.Have an active program for early detection of infested patients/residents and staff. Establish appropriate procedures for infection control and treatment.Maintain records with patient/resident name, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient/resident

before implementation of infection control measures: symptoms can take up to 2 months to appear in exposed persons and staff. (https://www.cdc.gov/scabies/php/public-health-strategy/index.html)

Event ID:

Facility ID:

If continuation sheet