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Deficiency Records for Medilodge of Sault Ste Marie
A list of the most recent deficiencies for Medilodge of Sault Ste Marie. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Medilodge of Sault Ste Marie. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-30 | 2024-08-22 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2024-07-30 | 2024-08-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-30 | 2024-08-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-30 | 2024-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-30 | 2024-08-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-07-30 | 2024-08-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-27 | 2024-07-30 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-06-27 | 2024-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-18 | 2024-05-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-18 | 2024-05-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-18 | 2024-05-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-29 | 2024-03-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-29 | 2024-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-29 | 2024-02-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-29 | 2024-02-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-29 | 2024-02-21 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-01-29 | 2024-02-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-29 | 2024-02-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-29 | 2024-02-21 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2024-01-29 | 2024-02-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-29 | 2024-02-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-29 | 2024-02-21 | Y |
| Have a Compliance and Ethics Program. | Health | 2024-01-29 | 2024-02-21 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-29 | 2024-02-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-29 | 2024-02-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-29 | 2024-02-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-29 | 2024-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-29 | 2024-02-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-29 | 2024-02-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-10 | 2023-10-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-05 | 2023-05-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-05 | 2023-05-31 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-05 | 2023-05-31 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-05 | 2023-05-31 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-01-31 | 2023-03-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-31 | 2023-03-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-31 | 2023-03-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-31 | 2023-03-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-01-31 | 2023-03-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-31 | 2023-03-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-31 | 2023-03-12 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-01-31 | 2023-03-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-31 | 2023-03-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-31 | 2023-03-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-31 | 2023-03-12 | N |
| 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. | Health | 2023-01-31 | 2023-03-12 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-01-31 | 2023-03-12 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-01-31 | 2023-03-12 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-01-31 | 2023-03-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-31 | 2023-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-31 | 2023-03-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-31 | 2023-03-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-31 | 2023-03-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-31 | 2023-03-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-31 | 2023-03-12 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-31 | 2023-03-12 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-31 | 2023-03-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-31 | 2023-03-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2023-03-12 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-31 | 2023-03-12 | Y |
| Post nurse staffing information every day. | Health | 2023-01-31 | 2023-03-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-31 | 2023-03-12 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-25 | 2023-03-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-25 | 2023-03-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-25 | 2023-03-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-25 | 2023-03-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-25 | 2023-03-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-25 | 2023-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-17 | 2021-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-17 | 2021-12-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-17 | 2021-12-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-17 | 2021-12-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-17 | 2021-12-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-17 | 2021-12-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-11-17 | 2021-12-17 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-11-17 | 2021-12-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-17 | 2021-12-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-17 | 2021-12-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-17 | 2021-12-17 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-11-17 | 2021-12-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-17 | 2021-12-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-17 | 2021-12-17 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-11-17 | 2021-12-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-17 | 2021-12-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-17 | 2021-12-17 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-11-17 | 2021-12-17 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
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