Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Medilodge Of Alpena during CMS and state inspections, most recent first.
A resident with multiple fractures, obesity, and other conditions, receiving rehab services and care-planned for a two-person assist with bed mobility, was repositioned in bed by a single CNA during a bed check. The resident reported that the CNA roughly swung his legs into bed, shoved his shoulder against a mobility bar, and then flopped him back onto his back. Documentation by an LPN confirmed the CNA was alone during the care, and the resident later told Social Services that the CNA was not gentle and that he might contact law enforcement. A DPT reported the resident complained of being roughed up and having increased neck pain afterward, and facility leadership acknowledged that the care plan requiring two-person assistance was not followed.
Failure to provide written bed hold notifications to residents and/or their representatives when residents were transferred to the ED or hospital. Multiple residents had no EMR documentation showing that the bed hold policy was given at transfer or afterward, and the NHA stated the facility was not issuing the required written information regardless of payor source. The facility policy required written bed hold information for all residents before transfer or therapeutic leave.
Insulin pens and vials on multiple medication carts were found without expiration dates, including one pen that had already passed its 28-day opened period and remained in active use. An LPN stated she did not know how long the insulin pens were good for, another LPN said the insulins were discarded after 28 days, and the DON stated the insulins should have both an opened date and an expiration date. Surveyors also observed an A-hall med cart left unlocked and unattended while two residents walked by it.
A resident with severely impaired cognition was observed smoking in the outdoor pavilion without the required smoking apron, while ashes drifted uncontrolled and she backed her wheelchair away from the table. The resident stated she usually wore a smoking apron and had difficulty holding a cigarette, and the DON confirmed the apron should have been in place. The EMR included a physician order and care plan entries for smoking safety aids, including a smoking apron and previously a cigarette holder.
Medication administration errors exceeded the allowed rate when an LPN gave a resident cyanocobalamin at the wrong dose, administered metoclopramide outside the ordered timing, and prepared and gave rapid-acting insulin inconsistently with manufacturer instructions. The insulin pen was primed while held sideways, injected in a different abdominal site than documented on the MAR, and held in place for only six seconds.
An LTC facility failed to maintain infection control for a resident on continuous oxygen and another resident during medication administration. Oxygen tubing and an unsheathed nasal cannula were observed resting on furniture, a handbag, and near the floor without a protective barrier, and an LPN placed reusable medication items directly on surfaces, returned an inhaler to the cart without sanitizing it, and reused an insulin pen after it fell to the floor without sanitizing it.
The facility failed to provide diabetic foot care for a resident with diabetes, as her toenails were excessively long and podiatry services were not offered upon admission. Additionally, another resident did not receive proper assessments and documentation during the new admission process, with missing vital signs and weights, and a lack of communication regarding a change in physician. These deficiencies indicate lapses in the facility's care processes.
The facility failed to ensure proper medication administration and disposal for two residents. A resident's medications were left unattended without supervision, contrary to their care plan. Another resident's pills were found on the floor and improperly disposed of in the trash by an LPN, instead of using the designated disposal methods. The DON was aware of the incidents.
A resident with intact cognition and multiple diagnoses experienced a delay in receiving ordered x-rays after an incident where their toes were run over by another resident. The x-rays were ordered by a physician but not executed until days later, after the physician inquired about the results. Facility staff interviews revealed a lack of awareness and communication regarding the order, and the Director of Nursing could not explain the delay, despite existing policies for timely diagnostic test completion.
A resident with a history of heart failure and other conditions was admitted for rehab but experienced a change in condition that was not properly recognized by the facility. Despite lab results indicating potential sepsis, the sepsis pathway was not followed, and vital signs were not consistently monitored. The resident's condition worsened, leading to hospitalization and death from septic shock and infected wounds.
The facility failed to prevent pressure ulcers in two residents, leading to severe health issues. One resident developed multiple stage 3 ulcers due to delayed interventions and inadequate documentation of care refusals. Another resident acquired a stage 3 heel ulcer, with insufficient preventive measures in place. Staff interviews revealed compliance issues and pain during wound care, with no wound cultures conducted.
The facility failed to serve meals at a palatable temperature, affecting numerous residents who reported consistently cold food. Despite complaints raised in resident council meetings, no corrective actions were documented. Observations revealed delayed meal service, contributing to cold food, and inadequate equipment to maintain food temperature. The facility's policy on prompt meal service was not followed, leading to resident dissatisfaction.
A facility failed to maintain a medication administration error rate below five percent, resulting in an 8.00 percent error rate. A nurse administered an incorrect dosage of metoclopramide to a resident and failed to flush the G-tube with water before medication and tube feeding, contrary to the facility's policy. The errors were confirmed by the DON.
Failure to Follow Two-Person Assist Care Plan During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to provide safe bed mobility and adequate supervision by not following a resident’s care plan requiring a two-person assist. The resident had been admitted with multiple serious injuries, including wedge compression fractures of the thoracic vertebrae, multiple left rib fractures, a left clavicle fracture, depression, and obesity, and was receiving rehabilitation services. The resident’s care plan identified an ADL self-care performance deficit related to multiple conditions and specified that bed mobility required a two-person assist. On the evening in question, a CNA entered the resident’s room alone to perform a bed check and reposition the resident, despite the care plan requirement for two staff. The resident reported that the CNA threw his legs over the bed “like a sack of potatoes,” wrenched his shoulder, shoved his left shoulder against the assist/mobility bar, and then flopped him back onto his back after stating he was dry and clean. The resident’s account of being “manhandled” and having his shoulder hit the mobility bar was documented in an incident report completed by the unit manager LPN, which noted that the CNA was the only person present during the repositioning and bed check. The resident later expressed to Social Services that the CNA was not gentle enough and stated he would consider calling the police and obtaining a personal protection order if necessary. A Doctoral Physical Therapist reported that the resident complained of being “roughed up” during care by the CNA and that he was experiencing more neck pain after the incident. The unit manager LPN and the Nursing Home Administrator both confirmed that there had been an incident during care and that there should have been two CNAs performing the bed mobility, acknowledging that the resident was not transferred properly in bed and that the care plan requirement for a two-person assist was not followed.
Failure to Provide Written Bed Hold Notifications
Penalty
Summary
The facility failed to provide written bed hold notifications to residents and/or their responsible parties when residents were transferred to the hospital or emergency department. The deficiency was identified for eight residents reviewed for hospitalizations, including residents who were sent out for conditions such as lethargy and decreased alertness, osteomyelitis, and multiple emergency department transfers. For several residents, the electronic medical record did not contain documentation or signed evidence that the resident or representative had been given the bed hold policy at the time of transfer or afterward. During interview, the Nursing Home Administrator stated the facility was not currently supplying bed hold information to residents or their representatives when they were transferred out to the hospital. He reported that the breakdown in communication among staff responsible for providing the information was unclear and acknowledged that the facility had not been issuing written bed hold information regardless of payor source. The facility policy stated that written information regarding bed hold policies was to be provided to all residents and/or representatives prior to transfer or therapeutic leave, including details about bed-hold duration, reserve bed payment policy, facility bed-hold procedures, and return conditions.
Insulin Pens and Medication Carts Left Improperly Labeled and Unsecured
Penalty
Summary
The facility failed to ensure safe storage and labeling of medications for three of three medication carts reviewed. On the A-hall medication cart, surveyors found five insulin pens without an expiration date, including one pen with an opened date that had already passed its 28-day use period and was still in the active medication supply. During interview, an LPN stated she did not know how long the insulin pens were good to use and said she would have to ask the unit manager, then acknowledged she needed to find out when to discard them. On the E-hall medication cart, surveyors found 13 insulin pens and two insulin vials without an expiration date. An LPN stated the insulins were discarded after 28 days, and when told another nurse would not know how long the insulin was good to use if pulled to work on any of the five units, she said the carts needed expiration dates added. On the D-hall medication cart, surveyors found one insulin pen without an expiration date, which an LPN verified. Surveyors also observed the A-hall medication cart unlocked and unattended for six minutes while two unidentified residents walked by it. The LPN later stated she had left the cart unlocked because she was helping another aide, and the DON stated the insulins should have an opened date and an expiration date on all of them.
Failure to Provide Required Smoking Safety Devices
Penalty
Summary
The facility failed to supply appropriate devices to ensure resident safety while smoking for one resident who was reviewed for safe smoking. Resident #104 was observed going to the smoking area and later smoking in the outdoor pavilion without wearing the required smoking apron. While smoking, the resident backed her wheelchair away from the table, did not use the ashtray, and flicked ashes from the burning cigarette into the air, with ashes drifting uncontrolled. The resident stated she usually wore a smoking apron and also said her fingers were so bad she could not even snap them, indicating difficulty holding a cigarette at times. The resident’s EMR showed a BIMS score of 6 out of 15, indicating severely impaired cognition. A physician order initiated on 9/25/24 directed that the resident wear a smoking apron at smoke times and that nursing ensure she had and was using it. The most recent quarterly/significant change evaluation listed smoking aids needed for safety as a smoking apron and cigarette holder, and the care plan included smoking apron use. During interview, the DON stated a cigarette holder had been removed from the care plan after a recent evaluation, but documentation of that revision was not produced and was not found in the EMR. The DON confirmed the resident should have had a smoking apron in place for protection while smoking.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with 3 errors identified during 25 observed medication administration opportunities, resulting in an error rate of 11.54 percent. During observation of medication preparation for Resident #94, an LPN dispensed cyanocobalamin 500 mcg, one tablet, into the medication cup even though the physician order was for cyanocobalamin 1000 mcg, one tablet by mouth daily at 8:00 AM for B-12 deficiency. The same resident’s metoclopramide 5 mg order was for administration before meals at 7:00 AM, 11:00 AM, and 4:00 PM, but the medication was given at 8:17 AM. When questioned, the LPN stated the resident’s breakfast trays arrived around 9:00 AM and said it made more sense for the medication to be given at 8:00 AM because the resident’s other medications were scheduled then. For Resident #126, an LPN prepared a rapid-acting insulin pen by dialing a test dose of 2 units and priming the pen while holding it horizontal instead of upright. The LPN then administered the insulin in the resident’s left lower quadrant and held the pen in place for only six seconds after injection. The MAR showed the insulin had been administered in the resident’s right upper quadrant of the abdomen. The DON stated staff are to refer to manufacturer guidelines for insulin, including priming the pen upright and holding it in place for ten seconds after injection. The report also cited the facility policy requiring medication administration according to the MAR and within 60 minutes before or after the scheduled time unless otherwise ordered.
Infection Control Lapses During Oxygen Use and Medication Administration
Penalty
Summary
The facility failed to maintain current infection control practices for a resident with heart failure, chronic respiratory failure, diabetes, and dementia who required continuous oxygen at 3 L/min via nasal cannula. The resident had moderate cognitive impairment and needed substantial to maximal assistance with personal hygiene and was dependent on staff for transfers and mobility. On observation, the portable oxygen concentrator was placed on the floor next to the resident’s room, and the oxygen tubing and unsheathed nasal cannula were observed draped over a bedside table with part of the tubing and cannula resting on a handbag, with no protective barrier between the tubing and the surface. On a later observation, the tubing was wrapped around the bed grab bar and the cannula was draped over the bed and resting near the floor. The facility also failed to maintain infection control during medication administration for another resident. An LPN placed the resident’s water, medication cup, and inhaler directly on a dining room table without a barrier, administered the inhaler, and then returned it to the medication cart without sanitizing it. During a later medication pass in the resident’s room, the LPN placed two insulin pens on the bathroom sink vanity without a barrier, handled the bathroom and bed transfer, washed hands, turned off the water with bare hands, and then moved the insulin pens to the bedside table. One insulin pen fell to the floor and was picked up and placed back on the bedside table without sanitizing it before both insulin injections were given. The DON stated staff should use a barrier when setting reusable medication items down and sanitize them, and that the insulin pen should have been sanitized after falling to the floor.
Deficiencies in Diabetic Foot Care and New Admission Assessments
Penalty
Summary
The facility failed to provide adequate diabetic foot care for a resident with diabetes mellitus. The resident was observed with excessively long toenails, and despite having a care plan that included diabetic foot checks, there was no documentation of podiatry services being offered upon admission. The Director of Nursing (DON) and a Nurse Manager acknowledged the oversight, noting that podiatry services had recently visited the facility, but the resident was not included in the list to be seen. The facility's policy required foot care in accordance with professional standards, but this was not adhered to in the resident's case. Another deficiency involved the improper assessment and documentation for a newly admitted resident. The resident, who had multiple active diagnoses including diabetes mellitus and atrial fibrillation, did not have vital signs recorded for two consecutive days as required by the new admission process. Additionally, the resident's weight was not obtained on one of the ordered days, and skilled nursing assessments were completed using outdated vital signs. The DON confirmed these lapses and acknowledged that the resident's change of physician was not communicated to the new provider, which delayed appropriate medical intervention. These deficiencies highlight a failure in the facility's processes for ensuring quality care and proper documentation. The lack of diabetic foot care and the failure to perform and document necessary assessments for new admissions indicate a breach in the facility's policies and procedures, impacting the residents' health management and care outcomes.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and disposal practices for two residents. For one resident, medications were left unattended at the bedside without supervision, despite the resident's care plan indicating no desire for self-administration. The resident confirmed that the nurse did not observe the medication intake, which contradicts the facility's policy requiring observation of medication consumption. For another resident, pills were found on the floor and were improperly disposed of in the trash by an LPN, rather than using the designated drug buster or sharps container as per facility policy. The resident had a physician's order for a controlled medication, which requires specific disposal procedures. The DON acknowledged awareness of the incident and confirmed the improper disposal method used by the LPN.
Delay in Obtaining X-Ray Services for Resident
Penalty
Summary
The facility failed to ensure timely radiology exams for a resident, leading to a delay in obtaining necessary x-rays. The resident, who had intact cognition, was admitted with diagnoses including hypertension, depression, diabetes mellitus, and gout. An incident occurred where the resident's toes were run over by another resident in a wheelchair, causing pain. A physician ordered bilateral foot x-rays on January 20th, but the order was not executed promptly. The x-rays were eventually ordered on January 23rd, after the physician inquired about the results and discovered the oversight. Interviews with facility staff revealed a lack of awareness and communication regarding the x-ray order. A Licensed Practical Nurse did not recall receiving the order, and a Registered Nurse only became aware of the need for x-rays after the physician's inquiry. The Director of Nursing was unable to explain the delay, despite the facility's policy requiring timely completion and tracking of diagnostic tests. The x-rays, when finally conducted, showed no fractures, but the delay in obtaining them was a clear deficiency in the facility's processes.
Failure to Recognize Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to recognize a change in condition for a resident, leading to hospitalization and death. The resident, who had a history of congestive heart failure, chronic obstructive pulmonary disease, morbid obesity, and muscle weakness, was admitted for short-term rehabilitation. Despite lab results indicating elevated BNP levels and low white blood cell counts, there was no follow-up or new orders from the physician. The sepsis pathway was not properly followed, and vital signs were not consistently monitored or communicated to the physician. The resident's condition deteriorated with signs of sepsis, including hypotension, tachycardia, and mental status changes. However, the sepsis screening tool was incorrectly marked as negative, and the SBAR documentation was not accurately completed. The resident's refusal to eat and worsening wounds were noted, but there was no increased monitoring or intervention. Interviews with staff revealed a lack of adherence to the sepsis protocol and inadequate documentation of the resident's condition. The resident was eventually transported to the hospital, where he was diagnosed with septic shock and deep decubitus ulcers. Despite aggressive treatment, the resident's condition continued to decline, and he passed away shortly after admission. The facility's failure to promptly recognize and respond to the resident's change in condition, as well as the improper use of the sepsis pathway, contributed to the adverse outcome.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to prevent the development of pressure ulcers for two residents, leading to significant health complications. Resident #70 was admitted with no open skin areas, but later developed multiple pressure ulcers, including stage 3 ulcers, which were not present upon admission. The facility did not implement timely interventions for the resident's skin conditions, and there was a lack of consistent documentation and follow-up on the resident's refusal of care and turning and repositioning schedules. The resident's wounds worsened over time, resulting in sepsis and hospitalization, requiring wound debridement. Resident #70's care plan indicated a risk for impaired skin integrity due to morbid obesity, congestive heart failure, and muscle weakness. Despite this, interventions such as a low air loss mattress were delayed, and the resident's refusal to comply with certain care measures was not adequately addressed. The facility's staff failed to consistently document the resident's behaviors and refusals, which contributed to the deterioration of the resident's skin condition. Interviews with staff revealed that the resident experienced significant pain during wound care, and there was no evidence of wound cultures being taken to guide appropriate antibiotic treatment. Resident #33 also developed a facility-acquired pressure injury on the right heel, which progressed to a stage 3 ulcer. The resident's care plan initially included measures to float heels, but additional interventions were not implemented until after the injury developed. Staff interviews indicated that the resident was compliant with care, yet there was a lack of documentation regarding any refusals or interventions prior to the development of the deep tissue injury. The Director of Nursing confirmed that more interventions should have been in place before the injury occurred, highlighting a deficiency in the facility's pressure ulcer prevention practices.
Deficiency in Meal Temperature and Timeliness
Penalty
Summary
The facility failed to provide meals at a palatable temperature, affecting 19 out of 23 residents interviewed. Multiple residents reported that their food was consistently served cold, regardless of the meal. This issue was raised during resident council meetings, but no corrective actions were documented or implemented by the Certified Dietary Manager (CDM) or the Nursing Home Administrator (NHA). The facility's policy on resident council meetings indicated that concerns should be investigated, but the NHA claimed to be unaware of ongoing complaints about food temperature. Observations and interviews revealed that meal service was often delayed, contributing to the cold temperature of the food. Residents expressed frustration with the timeliness of meal delivery, with some waiting up to 45 minutes for their meals. The delay in meal service was observed during a lunch service, where many residents had not received their meals on time, leading to dissatisfaction and complaints about the food being cold. The facility lacked proper equipment to maintain food temperatures during delivery, as noted by a CNA who mentioned that the small open carts used for meal delivery did not keep food warm effectively. Despite the presence of staff in the dining room, meal service was not prompt, and residents continued to express dissatisfaction with the temperature and quality of their meals. The facility's policy on meal service emphasized prompt delivery and accommodation of preferences, which was not adhered to, as evidenced by the residents' complaints and observations made during the survey.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in an error rate of 8.00 percent. This was identified during an observation of medication administration by RN J for a resident, R10. RN J was observed dispensing 2.5 ml of metoclopramide oral solution, which was incorrect according to the physician's order that required 5 ml to be administered via G-tube. Upon verification, RN J acknowledged the mistake and administered an additional 2.5 ml. This error was part of three errors identified out of 25 opportunities. Additionally, RN J failed to flush R10's G-tube with water before administering medications and before tube feeding, as required by the facility's policy. The Director of Nursing confirmed the errors and stated that the expectation was for nurses to follow physician orders and policy for medication administration via G-tubes. The facility's policy and validation checklist for medication administration via feeding tubes were reviewed, which emphasized the importance of flushing the G-tube with water before and between medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alpena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Green View | 0.7 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Hillman | 21.6 mi | ★★★★★ | 29 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 27.4 mi | ★★★★★ | 13 | 0 |
| Jamieson Nursing Home | 29.4 mi | ★★★★★ | 12 | 0 |
| Medilodge Of Rogers City | 30 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Medilodge Of Alpena.
100% money-back within 48 hours.
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.