Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gogebic Medical Care Facility during CMS and state inspections, most recent first.
A resident with cerebral palsy suffered aspiration pneumonia after an RN improperly replaced a feeding tube with a urinary catheter, leading to Immediate Jeopardy. The facility lacked proper training and policies for tube replacement, and securement devices were not used to prevent dislodgment. The resident was hospitalized and placed on comfort care due to the incident.
A resident with an L1 vertebral compression fracture experienced worsening of their condition due to the facility's failure to ensure proper application and use of a TLSO back brace. The resident was not educated on how to wear the brace correctly, and facility staff did not provide necessary assistance or education. The resident's care plans and CNA assignment cards lacked specific instructions, and the facility did not provide staff with the manufacturer's instructions for the brace until after the deficiency was identified. The Director of Nursing acknowledged the lack of staff training and reliance on therapy staff for guidance.
A resident was admitted to the ICU with aspiration pneumonia after a nurse incorrectly inserted a urinary catheter into the gastrostomy site. Interviews revealed that nurses lacked formal training and competency evaluations for feeding tube replacement, relying instead on informal guidance and online videos. The facility's assessment included tube feeding services, but training for this procedure was not provided.
The facility failed to offer and provide pneumococcal vaccinations to three residents, resulting in a deficiency. A resident with severe cognitive impairment was documented as having up-to-date vaccinations, but the MCIR indicated they were overdue. The resident developed pneumonia, was hospitalized, and passed away. Two other residents were also overdue for vaccinations, with no documentation of consent or administration. The Infection Preventionist confirmed outdated consent forms and failure to administer recommended vaccines.
The facility's assessment failed to include necessary training on resident rights, dementia care, behavioral health, ethics, and QAPI, potentially leaving the facility unprepared to meet the needs of its 80 residents. The DON and NHA acknowledged the deficiency, noting that the current training did not cover all required areas for the resident population.
A resident with severe cognitive impairment and a history of exit-seeking behavior was found unattended in a stairwell, posing a risk for falls and injury. The resident's wander guard bracelet was improperly attached to the wheelchair, allowing the resident to exit without triggering alarms. Staff were not adequately informed of the resident's elopement risk, and facility policies on wander guard use were not effectively implemented.
The facility failed to accurately inventory and account for controlled substances for a resident on end-of-life palliative care. Two vials of Morphine were reported missing, and it was found that oncoming and off-going shift nurses were not counting controlled substances together at shift change, contrary to standard practice and facility policy.
Improper Feeding Tube Replacement Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to replace a feeding tube in accordance with professional standards of practice for a resident, resulting in Immediate Jeopardy. A registered nurse (RN) inserted a urinary catheter with a 30 cc balloon into the gastrostomy site of a resident, which led to the resident experiencing blood-tinged vomiting, low oxygen saturation, and a decreased heart rate. The resident was transferred to the hospital, where an x-ray confirmed that the urinary catheter balloon was inflated in the resident's esophagus, leading to aspiration pneumonia and the resident being placed on comfort care measures. The resident, who had a primary diagnosis of cerebral palsy and was dependent on staff for all activities of daily living, had been using a catheter as a feeding tube for many years. The RN who inserted the catheter did not receive training or competency evaluations for changing a gastrostomy tube or inserting a urinary catheter as a feeding tube. The facility's Director of Nursing (DON) acknowledged that no training or competency evaluations had been completed for the nursing staff regarding these procedures. Additionally, the facility did not use securement devices to prevent dislodgment or migration of feeding tubes. The facility's policies did not include x-ray verification for placement after inserting an enteral tube, nor did they provide adequate guidance for ensuring proper tube placement. The DON confirmed that the medical director was not aware that the nurses had not been trained or competency-evaluated on changing feeding tubes or inserting catheters in lieu of feeding tubes. The facility's failure to adhere to professional standards of practice and provide adequate training and policies resulted in significant harm to the resident.
Removal Plan
- Resident R1 no longer has a foley catheter as a G-tube. The resident returned from the hospital with MIC-KEY low-profile tube in place.
- The physician clarified that the orders to change the G-tube if plugged or compromised in any way is to be done at the hospital. The nurses are not to change the tube.
- For current and new residents, all residents receiving tube feeding were assessed for the presence of a G-tube. Only one was identified. The physician clarified that the orders to change the G-tube if plugged or compromised in any way is to be done at the hospital. The nurses are not to change the tube.
- The physician ordered X-ray verification of the placement of current feeding tube to set a baseline for measuring.
- The facility's policies Gastric Tube Feeding and Policy and Procedure: Tube Feeding has been amended that the resident will be sent to the ED for replacement and measurements will be done to verify placement prior to medication administration, water flush, or start of formula. Also to notify the physician for any abnormalities including dislodging.
- The facility policy Insertion on indwelling catheter for gastric feeding has been removed.
- All nursing staff working day shift have been educated on the policy changes and competency tested for measuring.
Failure to Ensure Proper Use of Back Brace Leads to Worsening Fracture
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or prevent an avoidable reduction in range of motion for a resident with a spinal compression fracture. The resident, who had been diagnosed with an L1 vertebral compression fracture, was not wearing their TLSO back brace correctly, leading to a significant worsening of the fracture. The resident reported that they were not educated on how to properly apply the brace, and facility staff, including therapists and nursing staff, did not provide the necessary assistance or education. Observations and interviews revealed that the resident's back brace was not fitted correctly, and there was no physician order related to the use of the brace documented in the resident's records. The resident's care plans and CNA assignment cards lacked specific instructions for the application and use of the back brace, and the facility did not provide staff with the manufacturer's instructions for the brace until after the deficiency was identified. The resident's family member, who attended a neurosurgery appointment with the resident, confirmed that the brace was not being worn properly and that no education was provided by the hospital or the facility. The Director of Nursing acknowledged that the facility relied too heavily on therapy staff for guidance on the brace and confirmed that there was no documentation of staff training or education regarding the brace. The facility's failure to ensure proper application and use of the back brace resulted in harm to the resident, as the fracture worsened significantly due to the incorrect use of the brace.
Lack of Competency in Feeding Tube Replacement Leads to ICU Admission
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary knowledge, competencies, and skills to replace a feeding tube for a resident, leading to a serious incident. A resident, who was unable to consume food or fluids orally and required enteral feeding through a gastrostomy tube, was admitted to the ICU with aspiration pneumonia. This occurred after a registered nurse mistakenly inserted a urinary catheter into the resident's gastrostomy site, which was later found lodged in the esophagus with the balloon inflated. Interviews with nursing staff revealed a lack of formal training and competency evaluations for changing feeding tubes or using urinary catheters as feeding tubes. The registered nurse involved in the incident, as well as other nurses, confirmed that they had not received specific training or competency checks for these procedures. Instead, they relied on informal guidance from peers and online videos, which did not adequately prepare them for the task. The facility's Director of Nursing admitted that no training or competency evaluations had been conducted for the involved nurses regarding feeding tube replacement. The facility's assessment documented tube feeding as a service offered, yet the nurse education section did not include training for changing feeding tubes or using urinary catheters as feeding tubes. This oversight contributed to the incident, highlighting a significant gap in the facility's training and competency evaluation processes.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and provide pneumococcal vaccinations to three residents, resulting in a deficiency. Resident #28, who had severe cognitive impairment and was diagnosed with non-traumatic brain dysfunction, was documented as having up-to-date pneumococcal vaccinations in the Minimum Data Set (MDS). However, the Michigan Care Improvement Registry (MCIR) indicated that the vaccinations were overdue. The resident developed respiratory symptoms, was hospitalized for pneumonia, and subsequently passed away due to pneumonia-associated complications. The facility's records did not show that the PCV20 or PCV21 vaccinations were offered to the resident's guardian. Resident #44 was also documented in the MDS as having up-to-date pneumococcal vaccinations, but the MCIR showed that the vaccinations were overdue. There was no documentation in the resident's electronic medical record (EMR) indicating that the resident or their representative was offered or received the pneumococcal vaccinations. Similarly, Resident #1's MDS indicated up-to-date vaccinations, but the MCIR showed they were overdue, with no documentation of consent forms or vaccination administration in the EMR. The Infection Preventionist confirmed that the facility's consent forms were outdated and did not include the recommended PCV20 and PCV21 vaccines. The facility's policy stated that all residents eligible for pneumococcal vaccination should receive it after appropriate consent, but this was not followed. The lack of updated consent forms and failure to administer the recommended vaccinations contributed to the deficiency.
Incomplete Facility Assessment Lacks Essential Training Components
Penalty
Summary
The facility failed to complete a comprehensive facility assessment, which is necessary to determine the resources required to care for residents competently during both routine operations and emergencies. The assessment, last revised in January 2025, did not include essential training components such as resident rights, dementia care, behavioral health, ethics, and Quality Assurance Performance Improvement (QAPI). During an interview, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) acknowledged that the current competency and training did not encompass all the specific training required for the resident population. The NHA admitted that the facility needed to improve the facility assessment to include the necessary training for staff.
Inadequate Supervision Leads to Resident's Unattended Access to Stairwell
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R42, who was at risk for unsafe wandering. R42, who had severe cognitive impairment and was diagnosed with Alzheimer's Disease, was found unattended in a second-floor stairwell, posing a risk for falls and injury. The incident occurred when R42, who was independent with wheelchair use but required supervision for walking, was last seen in the Comfort Zone Unit dayroom before being found in the stairwell. The resident's wander guard bracelet was attached to the wheelchair rather than being worn on the body, which allowed R42 to exit the unit without triggering the alarm system. Interviews with facility staff revealed that R42 exhibited exit-seeking behaviors and had a history of traveling unassisted to the ground floor. Despite this, the wander guard bracelet was not properly utilized, and staff were not adequately informed of R42's risk for elopement. The Director of Nursing (DON) confirmed that R42 was at risk for unsafe wandering and acknowledged the failure in the alarm system due to the improper placement of the wander guard bracelet. Additionally, there was a lack of communication and documentation regarding residents at risk for elopement, as the binder listing such residents was not available at all necessary locations within the facility. The facility's policies on elopement and wander guard use were not effectively implemented, as evidenced by the incident involving R42. The care plan for R42 indicated a potential for elopement and required that the resident's whereabouts be known at all times, yet these measures were not adequately followed. The failure to ensure that R42 wore the wander guard bracelet and the lack of staff awareness contributed to the resident's unsupervised access to the stairwell, highlighting deficiencies in the facility's supervision and safety protocols.
Failure to Accurately Inventory and Account for Controlled Substances
Penalty
Summary
The facility failed to utilize a process for accurate inventory and accounting of controlled substances for one resident who was on end-of-life palliative care. The resident was prescribed Morphine Sulfate solution for pain management. On 4/30/24, two vials of the resident's Morphine were reported missing from the medication cart. The Nursing Home Administrator (NHA) confirmed that the last recorded count of the Morphine was on 4/24/24, and the missing vials were not located despite a search of the facility. The NHA also revealed that the oncoming and off-going shift nurses were not counting controlled substances together at shift change, which was a deviation from standard practice and facility policy. Interviews with the nursing staff indicated that the controlled substances were counted at varying times during shifts, and the process lacked consistency. One LPN admitted that she documented the inventory based on another nurse's verbal count without visually verifying the medications herself. The facility's Consultant Pharmacist confirmed that it is standard practice for oncoming shift nurses to verify the controlled substances inventory with off-going shift nurses. The facility's policy, updated in May 2024, also required this practice, but it was not being followed at the time of the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wakefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westgate Nursing & Rehabilitation Community | 9.9 mi | ★★★★★ | 5 | 0 |
| Sky View Nursing Center | 10.5 mi | ★★★★★ | 5 | 0 |
| Villa Maria Health And Rehab Ctr | 10.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.