Medilodge of Monroe
For profit - Corporation
103 Beds
MEDILODGE
Data: November 2025
Trust Grade
80/100
#147 of 422 in MI
Photo by Medilodge of Monroe
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Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Medilodge of Monroe has a Trust Grade of B+, indicating it is above average and recommended for families considering care options. It ranks #147 out of 422 facilities in Michigan, placing it in the top half, but is #6 out of 7 in Monroe County, meaning there is only one better local option. The facility is improving, with issues decreasing from 5 in 2024 to just 1 in 2025. Staffing is a strength, with a 4/5 star rating and a low turnover rate of 24%, much better than the state average of 44%. There have been no fines reported, which is a positive sign, though RN coverage is average. However, there have been some concerning incidents. For example, the facility failed to manage pain effectively for a resident, and there were issues with the cleanliness of the environment, which could lead to cross-contamination. Additionally, some residents reported their clothes were taken without notice, leaving them without appropriate attire for outings or appointments. Overall, while there are strengths in staffing and improvements in care, families should consider these incidents when making their decision.
- Trust Score
- B+
- In Michigan
- #147/422
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 24% annual turnover. Excellent stability, 24 points below Michigan's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Michigan facilities.
- Skilled Nurses ○ Average
- Each resident gets 40 minutes of Registered Nurse (RN) attention daily — about average for Michigan. RNs are the most trained staff who monitor for health changes.
- Violations ○ Average
- 7 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
80/100
Top 34%
Needs review
5 → 1 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 1 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (24%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (24%)
24 points below Michigan average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
Chain: MEDILODGE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 7 deficiencies on record
1 actual harm
Apr 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00151320.
Based on interview and record review the facility failed to properly assess and ensure pai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00151320.
Based on interview and record review the facility failed to properly assess and ensure pain was effectively managed for one resident (R901) of four residents reviewed for a fall with injury resulting in ongoing pain.
Findings include:
The survey agency received an allegation that the facility failed to effectively manage and assess pain.
On 4/1/25 at 9:05 AM, Family Member (FM) A was interviewed. FM A stated they were contacted on 3/10/25 by the unit manager. FM A said the unit manager asked them had anyone contacted her over the weekend. The FM A said no. FM A said they were told because R901 had to be given Lorazepam (anti-anxiety) medication, and they wanted to start R901 on Buspirone (ant-anxiety). FM A explained to the unit manager (UM) B that she did not want R901 placed on Buspirone. FM A said the next day she spoke with nurse supervisor (NS) C that told her despite her saying she did not want R901 on Buspirone he was given the medication. FM A said the unit manager (UM) B denied that her father was given the Buspirone.
Record review noted that R901 was initially admitted on [DATE] with a pertinent diagnosis of Acute Osteomyelitis of the Right knee and foot, Cerebral Infarction (stroke), Muscle Weakness, Lack of Coordination, and Chronic Pain.
Record review of R901 noted their Minimum Data Set (MDS) Annual Assessment on 3/14/25 for Brief Interview for Mental Status (BIMS) was moderately cognitively impaired with a score of 12 out of 15.
Record review of R901's Incident and Accident (I&A) report dated 3/4/25, documented on 3/4/25 at approximately 3:35 AM, that R901 had an unwitnessed fall. The I&A report noted that R901 was found lying on the floor and R901 was on their left side. Initially, the I&A report documented that R901 did not have any pain. Once assisted back to bed with the Hoyer lift R901 complained of pain. R901 complained of pain to the left ribs, left hip and left arm. R901 was given a dose of Tylenol 500 milligrams (mg) for a pain and an ice pack.
The Medication Administration Record (MAR) for March 2025, noted R901 had a stated pain score of six. The I&A report noted that the Medical Director (MD) D was contacted at 3:45 AM and ordered x-rays of the chest, left arm and left hip for R901.
Review of facility document Pain Evaluation dated 3/4/25, documented R901 pain score was a four. The location of the pain was to R901's left arm and left hip. The area impacted by the pain was R901's day to day activities.
According to [NAME] and [NAME] (2022) descriptive pain levels are as follows:
0-1
no pain
2-3
mild pain
4-5
moderate pain
6-7
severe pain
8-10
unbearable pain
Review of R901's care plan titled Care Plan Report initiated on 6/17/24 documented, Focus (R901) has/ is at risk for pain . Review of the care plan revealed the pain interventions were most recently reviewed on 2/28/25. However, R901 fell on 3/4/25 and sustained an injury. The care plan was not updated/reviewed at the time of the fall with injury. There were no new interventions added.
Record review of the facility document titled Skin Assessment dated 3/4/25/at 3:35 AM, documented that R901 did not have any new abnormal skin areas.
Review of document Skin assessment dated [DATE] at 9:06 AM documented R901 did not have any new abnormal skin areas.
Record review of document titled Radiology Report dated 3/4/25 noted that the X-rays were taken on 3/4/25 at 9:25 AM. The two view chest X-ray noted, no acute fracture. The X-ray of the hip noted, no fracture or dislocation. The X-ray of the humerus noted, no fracture or dislocation. The x-rays taken on 3/4/25 noted no breaks in bones. The facility Skin Assessments documented no abnormal skin areas. However, R901 complained of pain in these areas from 3/4/25 through 3/16/25 (the day of discharge to the hospital.)
Review of the MAR (March 2025) for R901noted the following orders.
Tramadol 50 mg 1 tab every 6 hrs. as needed was ordered on 3/4/25.
Medication documented as administered on the following dates:
On 3/4/25 at 10:30 AM-R901 pain score of 5. Documented as effective.
On 3/4/25 at 6:22 PM-R901 pain score of 4. Documented as effective.
On 3/5/25 at 4:09 AM- R901pain score of 5. Documented as effective.
On 3/5/25 at 10:19 AM-R901 pain score of 6. Documented as effective.
On 3/5/25 at 6:41 PM-R901 pain score of 6. Documented as effective.
On 3/6/25 at 8:00 AM- R901 pain score of 2. Documented as effective.
On 3/6/25 at 3:30 PM- R901pain score of 7. Documented as effective.
On 3/6/25 at 9:30 PM- R901 pain score of 8. Documented as effective.
On 3/7/25 at 8:45 AM- R901 pain score of 5. Documented as effective.
Percocet 5mg-325mg 1 tab every 6 hours as needed was ordered on 3/7/25 at 10:30 AM
The medication was administered on the following dates.
On 3/7/25 at 11:21 PM- R901 pain score of 7. Documented as effective.
On 3/8/25 at 6:23 AM- R901 pain score of 8. Documented as effective.
On 3/9/25 at 6:24 AM- R901 pain score of 10. Documented as effective.
On 3/9/25 at 2:59 PM-R901 pain score of 2. Documented as effective.
On 3/9/25 at 9:17 PM- R901pain score of 5. Documented as effective.
On 3/10/25 at 5:58 AM- R901pain score of 5. Documented as effective.
On 3/10/25 at 6:00 PM- R901pain score of 8. Documented as effective.
On 3/11/25 at 12:00 AM- R901pain score of 8. Documented as effective.
On 3/11/25 at 10:47 AM- R901pain score of 7. Documented as effective.
On 3/11/25 at 4:49 PM- R901pain score of 8. Documented as effective.
On 3/11/25 at 10:50 PM- R901 pain score of 8. Documented as effective.
On 3/12/25 at 6:30 AM- R901 pain score of 7. Documented as effective.
On 3/12/25 at 3:18 PM- R901 pain score of 8. Documented as effective.
On 3/13/25 at 8:27 AM- R901 pain score of 4. Documented as effective.
On 3/13/25 at 9:33 PM- R901 pain score of 3. Documented as effective.
On 3/14/25 at 9:17 AM- R901 pain score of 6. Documented as effective.
On 3/14/25 at 10:32 PM- R901 pain score of 2. Documented as effective.
On 3/15/25 at 7:41 AM- R901 pain score of 6. Documented as effective.
On 3/15/25 at 1:05 PM- R901 pain score of 8. Documented as effective.
On 3/15/25 at 9:10 PM- R901 pain score of 8. Documented as effective.
On 3/16/25 at 8:46 AM- R901 pain score of 5. Documented as effective.
Review of the MAR documented a pain score as reported by R901 prior to the administration of pain medication. However, there was no documented evidence of R901's stated pain score after the medication was administered and there was no evidence the facility implemented scheduled medication to manage R901's pain. Instead, the facility documented effective and continued to administer medications as PRN (as necessary).
Review of Electronic Medical Record (EMR) regarding R901, noted the following nursing notes:
On 3/8/25 at 8:11AM, License Practical Nurse (LPN) G documented R901, continues with groaning/calling out frequently. Repositioning, PRN medication, reassurance and redirection continues. Dr. notified with PRN lorazepam ordered q8hours PRN x1 day. 1st dose given at 0922 with positive results. Pt is resting in bed at this time.
On 3/9/25 at 8:04 AM UM B documented Nurse Practitoner (NP) G notified increased pain, no repeat xrays needed at this time.
On 03/10/2025 at 1:39 AM LPN H documented that R901 Resident yelling out, Resident was repositioned and given a Prn for pain.
On 3/14 at 3:05 PM UM B documented Spoke with daughter, related to pain meds and recent orders for antianxiety, stated that writer will have provider review meds on Monday, Related verbalized understanding.
On 3/16/25 at 1:53PM, LPN E documented R901, Yelling out randomly. Pain medications effective this shift. Poor appetite. Fluids encouraged and tolerated well.
On 3/16/25 LPN E documented R901, Daughter in to see R901t this afternoon. Daughter requesting resident be sent to Hospital regarding persistent pain to left side of body following most recent fall. Pain managed with pain medications and effective per resident. MD I contacted, per MD I offer repeat X rays and send to hospital if refused. Daughter declined x rays to be ordered and requested resident be sent to Hospital for evaluation of pain source. Ambulance transferred via stretcher to Promedica of [NAME] at about 1304. New clinical chart sent with resident handed off to EMS driver. Bed hold signed. SBAR completed.
On 3/17/25 LPN I documented, Called hospital for status on R901. R901 admitted to [NAME] hospital. R901 admitted for L femoral neck fracture along with L ribs 3-9 fractured.
On 4/1/25 at 12:55 PM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed. The DON explained that after R901 fell and before being discharged to the hospital there were times when R901 was not in pain. The DON added that they did not think there were any broken bones because there was no bruising or swelling on R901. The DON was queried if the R901 experienced another fall after the fall on 3/4/25. The DON said R901 did not have another fall after 3/4/25. The NHA did not offer any comment regarding R901's pain or concerns regarding hospital findings of R901 having a hip and fractured ribs.
Review of Policy titled Pain Management with revised date of 10/26/23 documented. The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
To help a resident attain or maintain his/her highest practicable level of well-being and to prevent or manage pain, the facility should:
Recognize when the resident is experiencing pain and identifies circumstances when the pain is
anticipated.
Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and with
change in condition or status (e.g., after a fall, with change in behavior or mental status).
Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences.
Dec 2024
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a mattress in a timely manner for one resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a mattress in a timely manner for one resident (R45) of one resident reviewed for accommodation of needs, resulting in the resident's sleep pattern being disturbed and verbalizing frustration of having back pain caused by an uncomfortable mattress.
Findings include:
On 12/15/2024 at 11:37 a.m., during an interview R45 pointed at the bed and said the mattress had a big hole in it and it was causing lower back pain. The resident reported the mattress was uncomfortable and having to find a higher part of the mattress to get a good night's sleep. R45 said it was reported to a staff member about three weeks ago or longer but was unsure of the staff member 's name. R45's mattress was observed with an observable indentation on the right side approximate to the middle of the bed.
According to the Electronic Health Record (EHR), R45 was admitted into the facility on [DATE] with diagnoses of history of falling, generalized epilepsy, dementia, anxiety disorder, extrapyramidal and movement disorder (involuntary motor activity), and osteoarthritis. R45's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R45 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15.
Review of the Activity Daily Living (ADL) care plan with a revision date of 11/22/2024, documented, Resident had an ADL self-care deficit . Interventions: Bed mobility one person assist.
On 12/17/2024 at 2:50 p.m. R45's assigned Certified Nursing Aid (CNA) A confirmed during an interview that the staff made R45's bed and if the resident needed a new mattress the nurses and the CNAs should have written the order in TELS (a computer system for documented requests, orders, and repairs for maintenance).
On 12/17/2024 at 3:11 p.m., Maintenance staff (MS) B said during an interview that it was reported that the resident needed and was requesting a new mattress. MS B confirmed the mattress did have a dip in it and the resident requested the mattress to be remove because R45 was not sleeping well. MS B was queried regarding the facility's protocol for requesting a new mattress. MS B said the staff should have filled out an order, documented in TELS and the order would have been completed for a new mattress, however there was no order put through for a new mattress until the resident was observed verbalizing frustration to a surveyor on 12/15/2024.
On 12/17/2024 at approximately 3:50 pm., the Director of Nursing (DON) confirmed the staff should have documented the resident mattress had a large indentation. The DON said the nurses and the CNAs should have observed the mattress because they would change the bed linen.
According to the revised 12/28/2023 Accommodation of Needs policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preference of a resident .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide nail care for two dependent residents (R5 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide nail care for two dependent residents (R5 and R66) of five residents reviewed for activities of daily living (ADLs), resulting in unmet care needs.
Findings include:
R5
On12/15/24 at 12:18 PM, R5 was observed in bed, on their back, wearing a gown. An interview was completed with R5 at this time. When asked regarding level of assistance required by staff to perform Activities of Daily Living (ADLs), R5 revealed they required extensive assistance due to a diagnosis of Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves causing numbness, weakness, trouble walking, vision changes and other symptoms). Their nails were observed as long in length, extending past the top of their fingers. R5 said that staff has not cut her nails in a while. R5 said, They keep telling me they will cut them during my shower, but I had my showers already .I have MS (Multiple Sclerosis).
On 12/16/24 at 10:18 AM, R5 was observed in bed, wearing a gown, and watching television. R5 was asked if their nails were trimmed and they said, They (staff) gave me a bed bath today, but I still need my nails cut.
A review of R5's electronic medical record revealed an admission on [DATE] with the diagnosis of Multiple Sclerosis, Functional Quadriplegia, Diabetes, Atrial Fibrillation, Convulsions, Muscle Weakness, and Stiff Joints. A review of R187's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was dependent for personal hygiene care. A review of R5's Care Plan revealed the following: Focus . Resident has an ADL self-care performance deficit .Intervention .Bathing: 2 person assist .Bed Mobility: 2 person assist .Personal Hygiene: 1 person assist .Dated 11/9/23.
R66
On 12/15/24 at 12:23 PM, R66 was observed sitting in their wheelchair watching television. An interview was completed with the R66 at this time. R66 said that their nails on her right hand needs to be cut. R66's nails were trimmed on their left hand but not on their right hand. Their right-hand fingernails were observed as long in length, extending past the top of their fingers. R66 said, It's frustrating because I can't cut my own nails.
On 12/16/24 at 10:44 AM resident was observed in the hallway in their wheelchair. The resident said that staff had not trimmed the nails on their right hand.
A review of R66's electronic medical record revealed an admission on [DATE] with the diagnosis of Cerebral Infarction, (an ischemic stroke, that occurs when blood flow to the brain is disrupted, depriving brain cells of oxygen and nutrients), Hemiplegia (one-sided muscle paralysis or weakness), Diabetes, Falls, Muscle Weakness, and Chronic Pain. A review of R66's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required substantial/maximal assistance with personal hygiene care. A review of R66's Care Plan revealed the following:
Focus .Resident has an ADL self-care performance deficit related to weakness, impaired mobility .Interventions .Personal Hygiene: 2 person assist .Dated 8/4/23.
On 12/17/24 at 01:30 PM, an interviewed was conducted with Certified Nurse Assistance (CNA) C and CNA D regarding residents receiving nail trims. Both CNAs stated that nail trims should occur on their shower days unless the resident ask.
On 12/17/24 at 03:18 PM, an interview was conducted with the Director of Nursing (DON) regarding nail care in the facility and R5 and R66 untrimmed nails. The DON said they (staff) should trim residents' nails during shower days. The DON also stated that staff will go to each unit to trim nails as needed.
Feb 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This information pertains to intake MI00142266.
Based on interview and record review the facility failed to maintain privacy for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This information pertains to intake MI00142266.
Based on interview and record review the facility failed to maintain privacy for one resident (R66) of two residents reviewed for privacy, resulting in the exposure of R66 on social media via video and texted message.
Findings include:
R66
Review of the medical record revealed R66 initially admitted into the facility on 1/31/2021 and readmitted on [DATE] with diagnoses of Alzheimer's disease, schizoaffective disorders, moderate protein-calorie malnutrition, major depressive disorder, and anxiety disorder. R66's Minimum Data Set (MDS), with a reference date of 12/13/2023, indicated R66 had severe cognition impairment with a BIMS (brief interview for mental status) score of 03/15. MDS assessment documented R66 was not able to be interviewed.
Review of the Activity Daily Living (ADL) care plan with revision date 2/12/2024, revealed Resident has an ADL self-care performance deficit related to weakness, impaired mobility, Alzheimer's disease, schizoaffective disease order, anemia, chronic pain, insomnia, anxiety, and depression. Interventions: Provide cues and assist as needed to accomplish daily tasks.
On 2/11/2024 at 9:56 a.m., R66 was observed asleep in bed with family at bedside. A concerned family member O said R66 had a decline in status and was not responding to anyone.
On 2/12/2024 at 12:00 p.m., an attempt to interview Family Member O regarding a complaint received by the State of Michigan of a video circulating on social media of R66 was made. However, Family Member O explained they were not available for a full interview due to the status of R66 but confirmed there was a video he had seen on social media of (R66). Family Member O explained he did not like it and said it was a violation of R66's privacy rights.
On 2/12/2024 at 12:15 p.m. the Facility Investigation Report revealed the following: On 2/19/2024 at 9:20 p.m. Nursing Home Administrator (NHA) received a phone call from Licensed Practical Nurse (LPN)/Afternoon Supervisor (N) stating that an anonymous caller called the facility and wanted to speak to the administrator in regard to a concern that involved a resident. On 2/10/2023 the administrator .was informed that a snapchat video had been sent out to three people. The Snapchat video included resident (R66) . In the video it shows (CNA L) her walking in to the residents room, shutting the door and stating let me introduce you (R66) . (CNA L) walking over to (R66) bed and trying to feed him with a spoon .The resident did not want to eat and the employee (CNA L) was just laughing.
On 2/14/2024 at 12:24 p.m., Concerned Person M confirmed CNA L text messaged the video to Concerned Person M and posted the video on a social media application of R66 in bed while assisting R66 at mealtime and announcing the resident's name prior to recording the video.
On 2/14/2024 at 11:42 a.m., an interview was conducted with the administrator and the Regional Director of Operation (RDO) K regarding an alleged circulating video of R66 on social media. The administrator was asked to recall an incident called in to the facility of a video circulating on social media of R66. The administrator stated, Yes, I am aware, and it happened before I started working in the facility.
RDO K explained the facility received a phone call that asked for the administrator on 2/19/2024 at approximately 9:00 p.m. RDO K said the administrator P that received the call is no longer employed at the facility. Administrator P contacted the caller back and the caller indicated that there was a video of the resident (R66) on a social media application and the video was reviewed by the caller and is in their possession. The caller indicated that an employee (Certified Nursing Assistant, CNA L) of the facility posted a video on social media and via text message of R66 lying in bed at mealtime being assisted with eating. Administrator P asked to review the video immediately, suspended the staff involved and started an investigation. Administrator P reviewed the video and substantiated that there was a video of R66 on social media and there was a social media policy violation. Administrator P terminated the employee. The former administrator (P) had the video. RDO K was asked did she reviewed the video. RDO K stated, I did because we met with the family (family member) and the resident's (R66)'s (spouse). RDO K said I was aware the family reviewed the video, I saw the CNA (CNA L) attempting to encourage the resident to eat one time, he kind of pushed the spoon away. RDO K added the CNA announced the resident's name prior to recording the video.
RDO K was asked how often the employees receive in-services on resident rights and abuse. RDO K said upon hire, annually and as needed, they are trained on resident's right, privacy and abuse and they are adherent to that. RDO K said it was not reported to the State of Michigan (SOM) because it was a social media violation (violation of privacy) for my understanding.
According to the facility's Social Media policy, revised date 1/1/2022, documented the following in part:
Do not use Social Media to post, upload, send, or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law . This prohibition includes . photos or video where the resident is easily identifiable.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R3
In an observation and interview on 2/11/24 at 1:09 p.m., R3 sat in a wheelchair in the room and wore a gown. R3 reported the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R3
In an observation and interview on 2/11/24 at 1:09 p.m., R3 sat in a wheelchair in the room and wore a gown. R3 reported the staff took their clothes without asking or let them know that they were taking them. R3 reported wanting to go to the dining room but did not have any clothes.
Review of an admission Record revealed, R3 admitted to the facility on [DATE] with pertinent diagnoses which included Depression.
Review of a MDS assessment, with a reference date of 12/4/23 revealed R3 had mild cognitive impairment with a BIMS score of 11, out of a total possible score of 15.
R54
In an observation and interview on 2/11/24 at 10:19 a.m., R54 sat in a wheelchair in the hallway and wore a gown with no socks or footwear. R54 reported they took all the clothes to wash them. R54 expressed there was a scheduled doctor's appointment the following day at 9:40 a.m. and currently did not have clothes to wear to the appointment.
Review of an admission Record revealed, R54 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included schizoaffective disorder.
Review of a MDS assessment, with a reference date of 2/5/24 revealed R3 had no cognitive impairment with a BIMS score of 15, out of a total possible score of 15.
In an observation and interview of 2/12/24 at 8:18 a.m., R54 sat in a wheelchair in the hallway and wore a gown. R54 reported I still do not (have) clothes and has an appointment this morning. R54 reported the staff gave her other residents clothes and R54 did not have a bra.
In an interview on 2/12/24 at 8:20 a.m. Certified Nursing Assistant (CNA) G reported the clothes provided to R54 came from the lost and found.
In an interview on 2/12/24 at 8:32 a.m., R54 reported feeling like s**t because R54 was not wearing her own clothes.
In an interview on 2/12/24 at 8:33 a.m., CNA G reported R54 clothes are still in laundry, and they are working to get the clothes back because there is a lot of clothes.
In an interview on 2/12/24 at 9:54 a.m., Laundry Aide B reported personal clothes are returned to residents in 72 hours. Laundry Aide B then reported all the resident personal items were sent to laundry a few days ago.
In an observation on 2/13/24 at 8:37 a.m., R54's closet contained one blouse and several empty hangers. A sign on the closet door read, Laundry by Family.
According to the facility's 10/26/2023 Promoting/Maintaining Resident Dignity policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality . 9. Groom and dress residents according to resident preference.
Based on observation, interview, and record review the facility failed to maintain the dignity of five residents (R3, R7, R37, R54 , and R58,) of six residents reviewed, resulting in the residents verbalizing their preferences to have their own personal clothing and frustration of not being completely dressed for breakfast while seated in the dining room (common area).
Findings include:
R7
On 2/11/2024 at 8:44 a.m., observed R7 sitting in the dining room in a gown, no socks, no shoes with both bare feet on the floor. R7 Stated, My feet are cold. R7 was observed rubbing both arms stating, My arms are cold. R7 arms were observed with no blanket nor sweater. During an interview, R7 stated, They (4 other residents) was not asked if they wanted to be dressed for breakfast or to eat in our rooms. They were just brought to the dining room and sat at the table for breakfast. I would like to be dressed in the dining room.
According to the medical record, R7 was admitted into the facility on 2/22/2019 with diagnoses of Alzheimer's disease, congestive heart failure, anxiety disorder, major depressive disorder, and osteoarthritis. R7's Minimum Data Set (MDS) with a reference date of 1/27/2024 indicated R7 had moderately cognition impairment with a BIMS (brief interview for mental status) score of 07/15.
Review of the 2/5/2024 Activity Daily Living (ADL) care plan revealed, Resident has an ADL self-care performance deficit related to weakness, impaired mobility, Alzheimer's disease, chronic obstructive pulmonary disease, diabetes mellitus, history of stroke, congestive heart failure, coronary artery disease, anxiety, depression, osteoarthritis, and dementia. Interventions: Dressing and transfers: one person assist. Allow time or resident to express feelings of frustration regarding the need for assistance in ADL tasks.
On 2/11/2024 at 10:23 a.m., Certified Nursing Assistant (CNA) H was interviewed regarding the residents not being properly dressed in the dining room. CNA H said, one of the residents was already up in the dining room from midnight shift. CNA H acknowledged bringing other residents in the dining room not properly dressed. CNA H confirmed the residents should have been fully and appropriately dressed for breakfast in the dining room.
R37
On 2/11/2024 at 8:44 a.m., observed R37 sitting in the dining room in a gown, no sweater, no socks, no shoes with both feet on the floor. R37 Stated, I am chilly, especially my arms. R37 was asked during an interview the choice to be dressed in the dining room for breakfast. R37 stated, I want to be dressed in the dining room.
According to the medical record, R37 was admitted into the facility on [DATE] with diagnoses of muscle weakness (generalized), major depressive disorder, anxiety disorder, and Alzheimer's disease. R37's quarterly Minimum Data Set (MDS) with a reference date of 9/15/2023 indicated R37 had severe cognition impairment with a BIMS (brief interview for mental status) score of 03/15.
Review of the 12/6/2023 Activity Daily Living (ADL) care plan revealed, Resident has an ADL self-care performance deficit related to weakness, impaired mobility, history of stroke, history of falls, chronic pain, seizures, dysphagia, anxiety, and Alzheimer's disease. Interventions: Allow resident to make choices/decisions about their preferred activity pursuits. Allow sufficient time for dressing and undressing. Assist resident with choosing minimally restrictive clothing to increase independence with dressing. Transfers and dressing one person assist.
R58
On 2/11/2024 at 8:44 a.m., observed R58 sitting in the dining room in a night gown, hair not groomed, no sweater, no socks, no shoes with both feet on the floor. R58 was asked if she wanted to be dressed for breakfast in the dining room. R58 responds with yes and no answers. R58 said yes to being cold and expressed wanting to be dressed at the breakfast table.
According to the medical record, R58 was admitted into the facility on [DATE] with diagnoses of muscle weakness (generalized), major depressive disorder, anxiety disorder, and Alzheimer's disease. R37's quarterly Minimum Data Set (MDS) with a reference date of 9/15/2023 indicated R37 had severe cognition impairment with a BIMS (brief interview for mental status) score of 03/15.
Review of the 11/15/2023 Activity Daily Living (ADL) care plan revealed, Resident has an ADL self-care performance deficit related to weakness, impaired mobility, seizure disorders, diabetes mellitus, intellectual disabilities, anxiety, depression and bipolar. Interventions: Transfers and dressing one person assist.
On 2/14/2024 at 10:53 a.m., the Director of Nursing (DON) was interviewed regarding residents being properly dressed in the dining room for meals. The DON said the residents should be dressed in the dining room at mealtime.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31
Review of an admission Record revealed, R31 admitted to the facility on [DATE] with pertinent diagnoses which included Obstr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31
Review of an admission Record revealed, R31 admitted to the facility on [DATE] with pertinent diagnoses which included Obstructive and Reflux Uropathy (blockage in the urinary tract) and Neuromuscular Dysfunction of Bladder (bladder malfunction which results in difficulty urinating).
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R31 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 6, out of a total possible score of 15 and required an indwelling catheter.
In an observation on 2/12/24 at 9:25 a.m., Certified Nursing Assistants (CNA) I and J provided ADL and catheter care for R31.
In an observation on 2/12/24 at 9:32 a.m., Staff Development Coordinator (SDC) A entered the room, applied gloves, and did not perform hand hygiene before application.
In an observation on 2/12/24 at 9:35 a.m., SDC A picked up cough drops and a cup off the floor with gloved hands. With the same gloves, SDC A then walked to R31's bed and touched R31's suprapubic catheter (catheter inserted through the stomach and into the bladder).
In an observation on 2/12/24 9:50 a.m., SDC A removed the gloves and exited the room while carrying bags of soiled linen. SDC A did not perform hand hygiene after glove removal.
In an interview on 2/12/24 at 9:51 a.m., SDC A reported gloves should be changed if they are soiled and between task to reduce contamination. SDC A reported gloves should be removed and hand hygiene performed after picking items up off the floor.
In an interview on 2/14/24 at 11:16 a.m., the Director of Nursing (DON) reported hand hygiene should be performed before and after glove use. The DON then reported gloves should be changed and hand hygiene performed after picking items up off the floor.
Review of a Hand Hygiene policy revised on 12/13/23 documented the following, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . The use of gloves does not replace hand hygiene. If your ask requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
Based on observation, Interview, and record review the facility failed to (1) ensure the ice scooper was properly stored during water pass and failed to (2) ensure proper hand hygiene was performed for one (R31) of one resident observed during care, resulting in the potential for the spreading of microorganisms throughout the facility.
Findings include:
On 2/11/2024 at 8:45 A.M., during an observation on the two hundred hall, Nurse Aide C and Nurse D was observed preparing ice water for the residents. Three pitchers filled with ice were observed on the ice cart with ice scooper on the side of the ice chest. The ice scooper was uncovered and not placed in an ice caddy/container to protect it from microorganisms or environmental contaminants.
Nurse Aide C reported the pitchers of ice were going to be used for the residents and the ice cart had been brought to the unit from the kitchen around 7:45 A.M. Nurse Aide C was asked about the ice scooper being uncovered and placed in the opened side slot. Nurse Aide C indicated the old ice chest had a cover for the ice scooper and thought this Ice cart/container should have some kind of cover, but it only had the attached, opened, slot for storage.
On 2/12/24 at approximately 3:50 P.M. on the three hundred hall staff was observed using an ice scooper that was not covered or stored in an ice caddy/container. Staff on this unit passed/offered ice water to the residents on the unit. The ice scooper was stored on the outside of the ice cart without any protection/covering or being placed in and ice caddy or container.
On 2/14/2024 at 11:53 A.M. during an interview with the Director of Nursing (DON) concerning the exposure of the ice scoop to microorganisms and possible contamination of the ice from residents wandering the halls, the DON stated the facility had recently purchased several Ice Chests and was unaware of the ice scooper not being protected or placed in an ice caddy or container.
In a subsequent observation of the ice storage bin stationed in the main dining room, the DON was presented with the concern related to the storing of the ice scooper outside of the ice cart without any protection. The DON explained the new carts were purchased with the attached opened storage slots but was unaware of the difference in the storage bins for the ice scooper. The DON thought the new ice storage/bins were the same as the previous ones used for passing ice.
According to the Code of Federal Regulation, Title 21, Volume8, section 1250.28 Ice Scoops should be stored in a clean container, outside of the ice supply. When the scoop is not being utilized keep it covered and protected from contamination.
Feb 2023
1 deficiency
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 91 residents, resulting in the increased likelihood for cross-con...
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Based on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 91 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.
Findings include:
On 02/07/23 at 04:35 P.M., An interview was conducted with Licensed Practical Nurse (LPN) Unit Manager H regarding the 2007 ARJO Spa Tub. (LPN) Unit Manager H stated: The spa tub leaks and has been out of service for approximately 1-1.5 weeks.
On 02/08/23 at 09:00 A.M., A common area environmental tour was conducted with Director of Maintenance K. The following items were noted:
200 Hall
Restroom A: The commode base caulking was observed (etched, cracked, stained, separated). Director of Maintenance K indicated he would have staff replace the damaged caulking as soon as possible.
Janitor Closet: The flooring surface was observed soiled with accumulated and encrusted dust and dirt deposits. Miscellaneous items (three plastic resin chairs, one plastic crate, damaged floor mop, etc.) were also observed stored within the disorganized janitor closet.
Shower Room: 3 of 6 overhead 48-inch-long fluorescent light bulbs were observed non-functional. The return exhaust ventilation grill was also observed soiled with accumulated dust and dirt deposits. The commode grab bar was additionally observed loose-to-mount. The 2007 ARJO Spa Tub was further observed with damaged and leaking water jets (2). The Spa Tub handheld wand assembly swivel connection was also observed loose-to-mount. The water supply control valve was additionally observed semi-seized, making the valve assembly very hard to actuate.
500 Hall
Staff Break Room: The microwave oven interior was observed (etched, scored, corroded, particulate). Director of Maintenance K indicated he would have staff remove and replace the damaged microwave oven as soon as possible.
Janitor Closet: The flooring surface was observed soiled with accumulated and encrusted (dust, dirt, grime). One extremely frayed broom was also observed resting on the soiled flooring surface.
400 Hall
Laboratory: The return exhaust ventilation grill was observed heavily soiled with dust and dirt deposits.
Janitor Closet: The flooring surface was observed soiled with accumulated and encrusted (dust, dirt, grime). The mop sink basin was also observed heavily soiled with accumulated and encrusted dust/dirt deposits.
Shower Room: One of two shower stall grab bars were observed loose-to-mount. Director of Maintenance K indicated he would have staff secure the grab bar as soon as possible.
100 Hall (Service Corridor)
Staff Locker Room: The floor metal heating duct cover was observed heavily corroded and particulate. Director of Maintenance K indicated he would replace the corroded heating duct cover as soon as possible.
300 Hall
Shower Room: The water pressure was observed low at the shower wand assembly dispensing head. The wand assembly dispensing head was also observed mineralized with calcium and lime deposits. The shower wand assembly connection was additionally observed missing an atmospheric vacuum breaker. The hand sink was further observed loose-to-mount. The space between the hand sink basin and wall surface measured approximately 0.5 - 1.0 inches wide.
On 02/08/23 at 10:45 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance K. The following items were noted:
203: The commode base caulking was observed (etched, scored, stained). The hand sink was also observed soiled, adjacent to the faucet perimeter.
204: The hand sink was observed soiled, adjacent to the faucet perimeter.
205: The hand sink was observed soiled, adjacent to the faucet perimeter.
206: The hand sink basin was observed draining slowly. The commode base caulking was also observed (etched, scored, stained, particulate).
210: The Bed B overbed light plastic protective cover was observed cracked and broken.
212: The Bed B and Bed C overbed light pull string extensions were observed missing.
309: The Bed B lower 48-inch-long fluorescent light bulb was observed non-functional.
311: The hand sink basin was observed draining slowly. The restroom over sink light assembly was also observed non-functional.
312: One of two hand sink basin support legs were observed resting against the restroom wall.
501: The commode base caulking was observed (etched, scored, stained, particulate).
505: The hand sink was observed soiled, adjacent to the faucet perimeter.
506: The hand sink was observed soiled, adjacent to the faucet perimeter.
508: One acoustical ceiling tile was observed stained from a previous moisture leak, adjacent to Bed B. The hand sink was also observed soiled, adjacent to the faucet perimeter.
On 02/08/23 at 12:25 P.M., An interview was conducted with Director of Maintenance K regarding the facility work order system. Director of Maintenance K stated: We have the TELS work order system.
On 02/08/23 at 01:35 P.M., Record review of the Direct Supply TELS Work Orders for the last 39 days revealed no specific entries related to the aforementioned maintenance concerns.
On 02/08/23 at 01:45 P.M., Record review of the Policy/Procedure entitled: Daily Patient Room Cleaning dated 06/2016 revealed under Timing & Method: (C) 2) Horizontal Dusting: With a cloth & disinfectant wipe all horizontal (flat) surfaces.
On 02/08/23 at 01:50 P.M., Record review of the Policy/Procedure entitled: Bathroom Cleaning dated 06/2016 revealed under Timing & Method: (B) WET Steps: 4) Sanitize sink, light, mirror, fixtures, and pipes. 5) Sanitize commode, tank, bowl & base. Use brush for inside of bowl.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (80/100). Above average facility, better than most options in Michigan.
- • No fines on record. Clean compliance history, better than most Michigan facilities.
- • 24% annual turnover. Excellent stability, 24 points below Michigan's 48% average. Staff who stay learn residents' needs.
Concerns
- • 7 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Medilodge Of Monroe's CMS Rating?
CMS assigns Medilodge of Monroe an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Michigan, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Medilodge Of Monroe Staffed?
CMS rates Medilodge of Monroe's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 24%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Medilodge Of Monroe?
State health inspectors documented 7 deficiencies at Medilodge of Monroe during 2023 to 2025. These included: 1 that caused actual resident harm and 6 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Medilodge Of Monroe?
Medilodge of Monroe is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MEDILODGE, a chain that manages multiple nursing homes. With 103 certified beds and approximately 91 residents (about 88% occupancy), it is a mid-sized facility located in Monroe, Michigan.
How Does Medilodge Of Monroe Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Medilodge of Monroe's overall rating (4 stars) is above the state average of 3.1, staff turnover (24%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Medilodge Of Monroe?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Medilodge Of Monroe Safe?
Based on CMS inspection data, Medilodge of Monroe has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Medilodge Of Monroe Stick Around?
Staff at Medilodge of Monroe tend to stick around. With a turnover rate of 24%, the facility is 22 percentage points below the Michigan average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 19%, meaning experienced RNs are available to handle complex medical needs.
Was Medilodge Of Monroe Ever Fined?
Medilodge of Monroe has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Medilodge Of Monroe on Any Federal Watch List?
Medilodge of Monroe is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.