Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Cheboygan during CMS and state inspections, most recent first.
Nebulizer Treatment Given Without Required Respiratory Assessment: An RN administered a nebulized respiratory treatment without documented pre- or post-treatment vital signs or lung sounds, did not instruct the resident to take deep breaths, and did not remain with the resident to observe for changes in condition. The resident's record showed no vitals documented around the treatments, and the treatment log, nurse assessments, and progress notes did not show a complete respiratory assessment for the ordered TID nebulizer therapy.
Failure to follow up on changes in condition for two residents. One resident with DM and hyperglycemia had a BG of 400 on the MAR, but there was no documented provider notification as ordered. Another resident on hospice had no BM for several days, with no documented bowel assessment, no constipation care plan, and no clear bowel protocol in place per staff interviews. The DON and nursing staff confirmed the physician should have been notified and that the bowel assessment should have been documented.
Failure to perform ordered wound care for a resident with a severe sacral pressure injury. The resident had Alzheimer’s disease, severely impaired cognition, and an infected Stage 3 sacral ulcer being treated with ciprofloxacin. The wound order required cleansing, Dakins-moistened gauze, a bordered dressing, and BID changes, but during observation the dressing was found saturated, partially adhered, and dated from the prior day. Staff documentation showed the care as completed, but the ADON confirmed the dressing had not been changed as ordered.
A resident with CKD and a physician-ordered 1200 ml fluid restriction was found with multiple beverages at bedside, including water and soda, while meal observations also showed additional fluids and a protein shake provided by family. Staff gave inconsistent accounts of who tracked intake, and the documented totals did not include all observed fluids, fluids given with meds, or fluids served with meals. The facility could only produce a general hydration policy, not a policy specific to fluid-restricted residents.
A resident with ESRD receiving off-site HD did not have a physician order for dialysis or for AV fistula monitoring, and staff did not document or report the need for an extra dialysis treatment related to fluid overload. The resident also had a 1,000 ml/day fluid restriction, but intake records showed repeated amounts above the allotted fluid allowance, and the care plan did not address fluid volume overload or noncompliance with the restriction.
Insulin administration errors occurred when two residents received injections that were not held in place for the full 10 seconds. An RN held one injection site for 6 seconds and another RN held a second injection site for 5 seconds, while both later stated the expected hold time was 10 seconds. The DON acknowledged staff should follow the 5 rights of medication administration, and the insulin guide instructed staff to count to 10 before removing the needle.
A resident with RSV had airborne, droplet, and contact precaution signs posted, but staff were observed exiting without PPE, a visitor entered with only a surgical mask, and nurses were unsure how to remove and discard PPE. The resident’s TBP order was delayed, and antibiotics started for suspected pneumonia continued even after a chest x-ray showed no acute abnormality. Another resident on RSV precautions had a CNA enter without PPE, and a third resident with a PEG tube had enhanced barrier precautions ordered, but an RN administered tube feeding wearing only gloves and not a gown.
Failure to Offer and Document COVID-19 Vaccination: The facility did not properly educate, offer, or document COVID-19 vaccination for two residents reviewed. One resident did not receive a COVID-19 consent form and was overdue for the 2025-26 vaccine, while another resident received only one dose and was overdue for the required follow-up dose. The RN confirmed the missed consent and overdue vaccination, and the facility policy referenced outdated CDC guidance.
A resident with severe cognitive impairment and multiple health issues was physically and verbally abused by a CNA during post-fall care, including being kicked, slapped, and subjected to derogatory language. Witnessing staff reported concerns to a supervising RN, but immediate protective actions were not taken, and the CNA continued to have access to residents until the Nursing Home Administrator was fully informed and intervened. The facility's abuse prevention protocols were not followed, resulting in psychosocial harm to the resident.
The facility failed to implement effective infection prevention and control practices, including improper isolation of COVID-19 positive residents, inadequate use of PPE, and poor medication handling. Residents were not properly isolated, and staff did not follow protocols for PPE removal and equipment disinfection. Additionally, medication handling practices were compromised by the use of ungloved hands, leading to potential contamination.
The facility failed to provide a dignified dining experience for three residents. A resident on hospice was ignored by a social worker and fed facing away from others. Another resident received a cold meal left uncovered, and a third resident waited to be fed while watching others eat. Additionally, a resident was pulled backward in a chair down the hallway without staff intervention. The Nursing Home Administrator acknowledged these actions were inappropriate.
The facility failed to properly dispose of contaminated medications for three residents. An RN dispensed acetaminophen into her hand and discarded it in the garbage, another RN dropped a vitamin on the cart and disposed of it in a biohazard container, and an incorrect dosage of potassium was discarded in the garbage. The facility's policy requires using a drug destroyer for medication disposal, which was not followed.
Two residents experienced medication administration errors, including incorrect dosages and delayed administration due to unavailable medication. A nurse prepared the wrong dosage of potassium and administered an incorrect dosage of Ativan due to outdated instructions. Another resident's meloxicam was delayed, causing severe pain, and was falsely documented as administered on time. The facility's policies on medication administration and documentation were not followed.
Two residents experienced significant medication errors due to the facility's failure to administer medications as prescribed. One resident suffered severe pain due to a delay in receiving meloxicam, while another received incorrect dosages of Ativan for anxiety. The errors were compounded by inadequate communication with the pharmacy and lack of proper documentation and physician notification.
A resident with severe cognitive impairment and multiple diagnoses experienced harm due to the facility's failure to assess and communicate a change in condition. After sustaining a fall and skin tear, the resident's condition worsened without timely wound assessments or notifications to medical staff. This led to a hospital transfer where severe infection and necrotizing fasciitis were diagnosed, requiring surgical intervention.
A facility failed to provide written notification for a facility-initiated discharge to a resident's representative and the LTC Ombudsman. The resident, diagnosed with schizophrenia, was transferred to the ED and later admitted to a psychiatric facility. Despite an expected return, the facility did not provide a discharge notice or appeal information when deciding not to accept the resident back, considering them discharged due to an extended absence. The resident's legal guardian was only informed when asked to pick up the resident's belongings.
Nebulizer Treatment Given Without Required Respiratory Assessment
Penalty
Summary
The facility failed to provide assessment, monitoring, and care per facility policy and professional standards for a nebulized respiratory treatment for one resident. During medication administration on 4/13/26 at 7:30 PM, RN B was not observed performing vital signs or a respiratory assessment/lung sounds before or after the nebulizer treatment. RN B did not instruct the resident to take deep breaths during the treatment and did not remain with the resident to observe for any change in condition. After the treatment, RN B told the resident, "shh I am trying to listen to your lungs," leaned closer to the resident, and did not have a stethoscope. During an interview later that evening, RN B stated that lung sounds should be listened to before and after treatment and said she felt she had completed a respiratory assessment. Review of the resident's EMR showed no vital signs documented since 7:24 AM on 4/13/26 and no additional vitals until 8:15 AM on 4/15/26, confirming no vitals were completed before or after nebulizer treatments. Review of the treatment log, nurse assessments, and progress notes did not show a complete respiratory assessment for any of the resident's three-times-daily nebulizer treatments ordered on 4/9/26. The facility's Nebulizer Therapy policy required vital signs and a respiratory assessment to establish a baseline, observation during the procedure, and documentation of vital signs, respiratory assessment, and response to treatment.
Failure to Follow Up on Changes in Condition
Penalty
Summary
The facility failed to ensure follow-up to changes in condition for two residents. One resident had Type 2 diabetes mellitus with hyperglycemia and was ordered Accuchecks before meals and at bedtime, with provider notification required for blood sugars of 70 or below or above 400. Review of the April 2026 MAR showed a blood glucose reading of 400, but there was no documentation that the provider was notified as ordered. A second resident, who had a history of constipation and was receiving hospice services, had no documented bowel movement for several days. The hospice RN note documented no bowel movement since 4/6/26, but there was no bowel/abdominal assessment documented by hospice and no care plan for decreased GI motility or constipation in the EMR. Facility staff stated that residents without a bowel movement for three days were to be placed on a bowel protocol, but the NHA and corporate director said they did not have a bowel policy or standing orders containing a bowel protocol, and no laxative medications were documented as having been given. Interviews with the DON and nursing staff confirmed that the last documented bowel movement was six days earlier, that the physician should have been notified, and that a bowel assessment should have been completed and documented. The DON also acknowledged that constipation was painful and that the resident had a history of constipation, but there was no response given when asked why constipation had not been care planned. The record later showed the resident had a bowel movement after the concerns were identified.
Failure to Perform Ordered Wound Care
Penalty
Summary
The facility failed to ensure wound care was completed according to the physician order and professional standards of practice for a resident with Alzheimer’s disease and severely impaired cognition who had an unhealed, facility-acquired Stage 3 sacral pressure ulcer. The resident was also being monitored for signs and symptoms of sepsis, and the April 2026 MAR showed ciprofloxacin was prescribed for wound infection. The treatment order required the sacral wound to be cleansed, packed with Dakins-moistened gauze, covered with a bordered dressing, and changed twice daily. During observation of wound care, the resident’s sacral dressing was found partially adhered, saturated with brownish-tan drainage, and dated and initialed from the prior day, despite the order for twice-daily dressing changes. The wound was large, approximately 8 cm by 7 cm with a depth of about 4 cm, had a beefy red wound bed with scattered white slough, and had a foul odor. The ADON confirmed the initials and date on the soiled dressing indicated the last change had been done the previous day shift, and the DON acknowledged the concern that wound care had not been performed as ordered. Although the TAR and charting documented wound care as completed on the scheduled shifts, the observed dressing and staff confirmation showed the ordered care had not been provided as documented.
Failure to Monitor and Document Fluid Restriction Intake
Penalty
Summary
The facility failed to monitor fluids and provide the diet as ordered for one resident with diagnoses including altered mental status, chronic kidney disease, hypertension, and urinary retention. The physician ordered a 1200 ml fluid restriction with a regular diet and thin liquids. The care plan identified the resident as at risk for fluid volume deficit and included interventions to encourage fluids unless contraindicated, offer fluids during activities, and ensure beverages complied with diet and fluid restrictions. The care plan was later updated to include the 1200 ml daily fluid restriction and provision of a protein shake with each meal. During observation, the resident had multiple fluids at bedside that were not reflected in the documented intake totals. One morning observation found two 16 oz cups at bedside, one with a brown carbonated beverage and one with ice water, plus a 12 oz cola bottle with about 3 oz remaining. Another observation later showed a 16 oz cup filled with ice water, and the resident was also observed eating a meal that included lemonade. The family member stated the protein shake was given in the room and that she brought in the shakes daily and made sure the resident received the supplement at every meal. Staff interviews showed inconsistent understanding and tracking of the resident's fluid intake. A nurse aide stated she filled cups the same for everyone on the hall and passed water twice per day. An RN stated the resident received only sips at med pass and confirmed that fluid given with medications was not accounted for. The DON stated she expected a focus addressing fluid restriction, while the ADON said daily totals were not totaled by nursing and the RD totaled fluids, although the RD stated she did not total the fluids and was not present every day. The documented CNA intake totals did not reflect all observed fluids, the protein shakes, fluids given with medications, or fluids served with meals. When asked for a policy on fluid restrictions, the facility provided only a general hydration policy and did not present a policy addressing fluid-restricted residents or documentation of fluid totals.
Dialysis Orders, Access Monitoring, and Fluid Restriction Not Followed
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with ESRD who received off-site hemodialysis. The resident’s EMR did not contain a physician’s order for dialysis and did not contain an order for monitoring the dialysis vascular access site. The DON confirmed there was no dialysis order and no daily monitoring order for thrill and bruit, and the ADON stated there should have been orders for the dialysis location, treatment frequency, and vascular access monitoring. The resident had an AV fistula, and staff were expected to monitor it for thrill, bruit, bleeding, signs and symptoms of infection, and other complications. The resident required an additional dialysis treatment because of fluid volume overload, but the physician was not notified and the reason for the extra treatment was not documented in the EMR. The DON reviewed the record and found no documentation explaining why the additional dialysis treatment was needed, and no progress note documented communication to the physician. RN G stated the physician should have been notified and the nurse should have called the dialysis unit to determine why the extra treatment was required. The dialysis communication form noted a dietary concern for fluid gain and a 20.3 pound gain since the last treatment, but there was no documentation that the facility addressed or responded to the fluid gain. The resident also had a physician’s order for a 1,000 ml per day fluid restriction, with 520 ml to be provided by dietary and 480 ml by nursing. The RD documented that the resident was agreeable to the restriction, but meal fluid intake documentation showed repeated intakes above the allotted amount, including 720 ml, 960 ml, 600 ml, 760 ml, 840 ml, 720 ml, and 1,200 ml on different days in April. The care plan did not include interventions for fluid volume overload or indicate noncompliance with fluid restrictions, and the MDS did not document refusals of care or behaviors. RN G stated CNAs documented only meal fluids and nurses did not document other fluid intake, while the RD confirmed excess fluid intake or noncompliance should be included in care plans.
Insulin Administration Errors
Penalty
Summary
Medication administration was not accurately performed for two residents during insulin administration, resulting in 2 errors in 34 opportunities for error and a 5.88% medication error rate. On 4/13/26, RN B was observed administering insulin to Resident #2 and held the subcutaneous injection site for six seconds. When interviewed immediately afterward, RN B stated the injection site should be held for ten seconds and acknowledged she had only held the needle in place for six seconds. Later that same evening, RN C was observed administering insulin to Resident #11 and held the subcutaneous injection site for five seconds. During interview, RN C stated the injection site should be held for ten seconds and acknowledged she had only held the needle in place for five seconds. The DON stated nurses should follow the five rights of medication administration and said some insulin pens had different administration times, but staff should always do ten seconds to be safe. The insulin step-by-step guide stated to slowly count to 10 before removing the needle to ensure the full insulin dose is received.
Infection Control Failures With PPE Use, Precaution Orders, and Antibiotic Continuation
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program for residents on transmission-based precautions and enhanced barrier precautions. For a resident with RSV, airborne, droplet, and contact precaution signs were posted outside the room, but staff did not consistently follow the posted PPE instructions. A CNA exited the room without PPE, a visitor entered after applying only a surgical mask, and nurses were observed unsure where PPE should be removed and discarded. The airborne precautions sign also directed respirator removal after exiting the room, but staff reported removing and disposing of the N-95 inside the room because there was nowhere outside the room to discard it. The infection preventionist stated the facility practice was to use standard, droplet, and airborne precautions for RSV, and also stated the resident should have had gowns, gloves, goggles or face shields, and an N-95 respirator. The resident’s record showed RSV was identified on 4/10/26, but there were no physician orders for transmission-based precautions until 4/13/26, three days later. The record also showed the resident was initially treated for suspected pneumonia with Rocephin and Levaquin after a progress note documented congestion, malaise, and cough. A chest x-ray obtained the next day showed no acute abnormality, yet Levaquin continued to be administered afterward. The infection preventionist stated the NP acknowledged the chest x-ray result but the note did not include a reason for continuing the antibiotic, and stated antibiotics would not be beneficial for RSV because RSV is a virus. Another resident with RSV had a physician order for transmission-based precautions and nursing notes stating the resident remained in droplet, contact, and airborne precautions. During lunch tray delivery, a CNA entered the room carrying the tray without gloves, gown, or face covering, despite signage outside the room directing staff to use gloves and gown for contact precautions and eye, nose, and mouth protection for droplet precautions. A third resident had a PEG tube and an order for enhanced barrier precautions during high-contact care. The door sign directed staff to wear gloves and a gown for feeding tube care, but when a nurse administered the tube feeding, only gloves were worn. The nurse stated she never wears a gown for a tube feed, while a regional RN stated gloves and gown should be worn for that activity.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document vaccination status for two residents reviewed for immunizations. Resident #2 was admitted to the facility, and while vaccination consent forms for pneumococcal and influenza vaccines were electronically signed, a COVID-19 vaccination consent form was not found in the medical record. A review of the Michigan Care Improvement Registry showed Resident #2 was overdue for the 2025-26 COVID-19 vaccine. During interview, the RN responsible for tracking vaccine consents and administrations confirmed Resident #2 was not provided the COVID-19 vaccination consent form when admitted. Resident #4 was admitted to the facility and signed consent for COVID-19 vaccine administration, and received one dose of the COVID-19 vaccine on 10/6/25. However, the Michigan Care Improvement Registry showed the resident’s 2025-26 COVID-19 vaccine had an accelerated due date of 12/6/25 and was overdue as of 4/6/26. When interviewed, the RN acknowledged Resident #4 should have received the second COVID-19 vaccination on or before 4/6/26. The facility policy on COVID-19 vaccination stated the facility would educate and offer the COVID-19 vaccine to residents and staff, but the policy referenced outdated guidelines and vaccines no longer in use or recommended by the CDC.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease and a history of stroke, was subjected to physical and verbal abuse by a Certified Nurse Aide (CNA) during post-fall assistance. The resident, who was non-ambulatory and required staff assistance for activities of daily living, was found on the floor after a fall. During the process of returning the resident to bed, CNA C was observed by two other CNAs to have kicked the resident multiple times, slapped the resident on the buttocks, and used derogatory language, calling the resident 'disgusting' in a loud and angry voice. The resident's disposable brief had fallen off, leaving him exposed during the incident, and he appeared startled, afraid, and in distress according to witness accounts. Despite witnessing the abuse, the initial response from staff was inadequate. CNA A reported discomfort with CNA C's actions to the supervising RN, but did not explicitly state that abuse had occurred, as she believed it was not her role to determine abuse but to report concerns. The RN did not immediately intervene, interview the involved staff, or remove CNA C from resident care duties. Instead, the RN delayed entering the resident's room and only reported the concern to the Nursing Home Administrator (NHA) after assessing the resident, without taking immediate protective measures or suspending the alleged abuser. The NHA was not made fully aware of the extent of the abuse until later in the day, after which CNA C was suspended and an investigation was initiated. Prior to this, CNA C continued to have access to residents. The facility's abuse prevention protocol, which requires prompt protection of residents and immediate reporting and investigation of abuse allegations, was not followed by the staff involved. The failure to act promptly and decisively resulted in psychosocial harm to the resident, including feelings of humiliation and fear, as substantiated by the facility's investigation.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to implement effective infection prevention and control practices for several residents, leading to potential transmission of communicable diseases. Residents with COVID-19 were not properly isolated, as room doors were left open despite signage indicating Transmission-Based Precautions (TBP). Additionally, there were no physician's orders or care plans for some residents placed in TBP. Staff members were observed exiting rooms of COVID-19 positive residents without removing personal protective equipment (PPE) and cleaning contaminated medical equipment in the hallway, contrary to infection control policies. In several instances, staff did not ensure that residents with COVID-19 wore masks or stayed in their rooms, increasing the risk of spreading the virus. For example, a resident was seen in the hallway without a mask, and staff did not redirect him back to his room or provide a mask. Another resident's face shield, which was potentially contaminated, was not properly disinfected after falling to the floor, and staff failed to address this breach in protocol. Medication handling practices also contributed to the deficiency. A nurse was observed using ungloved fingers to handle medications, contaminating them and the medication containers. The nurse also improperly handled blister packs by holding them against her uniform, which is against infection control standards. These actions were not in line with the facility's policy to prevent contamination during medication administration.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents, resulting in potential feelings of frustration, embarrassment, and humiliation. Resident #18, who was on hospice services and dependent on staff for eating, was observed in the dining room seated next to a hospice Social Worker who was preoccupied with a cell phone and laptop, not interacting with the resident or offering fluids. When the meal was finally served, the resident was turned away from the table and fed facing away from other residents. Resident #20 received a meal that had been left uncovered for approximately 11 minutes, resulting in cold food. Although a fresh meal was provided, the resident was not given a new roll or vegetables, and the original meal remained on the table. Resident #58, dependent on staff for all activities of daily living, was left waiting to be fed while watching other residents being assisted. When finally attended to, the meal was not reheated or checked for appropriate temperature. Additionally, Resident #18 was observed being pulled backward down the hallway in a high-back mobile reclining chair by a hospice CNA, with no intervention from other staff present. The Nursing Home Administrator acknowledged that the expectation was for all staff, including contracted personnel, to treat residents with dignity and respect, and that the observed actions were inappropriate. The facility's policy on promoting and maintaining resident dignity emphasizes treating each resident with respect and ensuring interactions are resident-focused, which was not adhered to in these instances.
Improper Disposal of Contaminated Medications
Penalty
Summary
The facility failed to appropriately dispose of contaminated medications for three residents during medication administration. For Resident #61, a Registered Nurse (RN) dispensed acetaminophen tablets directly into her hand and then discarded them into a garbage container after realizing the contamination. Similarly, for Resident #50, an RN dropped a vitamin on the medication cart and disposed of it in a biohazard container. In the case of Resident #47, an RN prepared an incorrect dosage of potassium, and upon realizing the error, disposed of the excess medication in the garbage container. The facility's nurse manager confirmed that the expected procedure for disposing of medications involved using a drug destroyer solution, which was available at the facility. However, the medications were not disposed of according to this protocol. The facility's policy on medication destruction specifies that drugs should be rendered unfit for human consumption by combining them with a drug destroyer or similar agent, which was not followed in these instances.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to ensure the correct dosages of prescribed medications were administered to two residents, resulting in a medication error rate of 9.38%. For one resident, a registered nurse (RN D) prepared and almost administered 20 milliequivalents (mEq) of potassium instead of the prescribed 10 mEq. This error was caught by a surveyor before administration. The mistake occurred because the blister pack of another resident was incorrectly placed in the medication cart section of the resident in question. Additionally, RN D administered an incorrect dosage of Ativan, giving only one tablet of 0.5 mg instead of the prescribed two tablets, due to outdated blister pack instructions. Another resident was prescribed meloxicam for pain, which was not administered as scheduled due to the medication not being available in the facility. The medication was ordered after the pharmacy's cut-off time, and the pharmacy was not contacted for a stat delivery. The resident experienced severe pain, rated ten out of ten, due to the delay. The medication was eventually administered using a supply brought in by the resident's family, but the administration was falsely documented as having occurred at the scheduled time. There was no documentation of the delay or notification to the physician about the unavailability of the medication. The facility's policy on medication errors requires that medications be administered according to the physician's orders, and any discrepancies should be documented and reported. However, in these cases, the nurses failed to adhere to these protocols, resulting in incorrect dosages and delayed administration without proper documentation or physician notification. The nurse managers confirmed that the expected procedure was not followed, highlighting a lapse in adherence to the facility's medication administration policies.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as prescribed for two residents, leading to significant medication errors. Resident #224 was prescribed meloxicam 15 mg daily for pain, but the medication was not administered as scheduled at 8:00 a.m. on 1/15/25. The medication was not available in the facility's emergency supply, and the pharmacy had not delivered it due to a late order. As a result, the resident experienced excruciating pain, rated ten out of ten. The medication was eventually administered at 2:37 p.m. using a supply brought in by the resident's family, but there was no documentation of the late administration or notification to the physician. Resident #47 was prescribed Ativan 1 mg three times daily for anxiety, but received an incorrect dosage due to a discrepancy between the physician's order and the medication available in the facility. The resident's blister pack contained lorazepam 0.5 mg tablets, and only one tablet was administered instead of the required two. This error occurred multiple times, and there was no documentation of the correct dosage being administered consistently. The facility's policy on medication errors emphasizes the importance of administering medications according to the physician's orders and documenting any significant errors. The facility's failure to adhere to medication administration protocols resulted in significant medication errors for both residents. The lack of timely communication with the pharmacy and the absence of proper documentation and physician notification contributed to these deficiencies. The facility's policy requires that any significant medication error be assessed, documented, and communicated to the prescriber, which was not followed in these cases.
Failure to Assess and Communicate Change in Condition
Penalty
Summary
The facility failed to ensure appropriate assessments and communication for a change in condition for a resident, resulting in harm. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and diabetes, was admitted to the facility and later transferred to a hospital due to mental status changes. The resident was found to have a severe wound infection that required intravenous antibiotics and surgical intervention. The resident sustained a fall resulting in a skin tear, which progressed into cellulitis. Despite the resident's increased confusion and behavior changes, there were no documented wound assessments or notifications to the wound care nurse or physician until several days later. The resident's condition worsened, leading to a hospital transfer where extensive cellulitis and necrotizing fasciitis were diagnosed, necessitating multiple surgical debridements. The facility's failure to conduct timely wound assessments and communicate changes in the resident's condition to the appropriate medical personnel contributed to the resident's deteriorating health. The facility's policy required notification of changes in condition, but this was not adhered to, resulting in delayed treatment and increased harm to the resident.
Failure to Provide Written Notification for Facility-Initiated Discharge
Penalty
Summary
The facility failed to provide written notification for a facility-initiated discharge to a resident's representative and the Office of the State Long-Term Care Ombudsman. This deficiency involved a resident with a primary diagnosis of schizophrenia who was transferred to the emergency department for psychological evaluation and subsequently admitted to a psychiatric facility. Despite the resident's legal guardian receiving a transfer notice indicating an expected return, the facility did not provide a written discharge notice or appeal information when they decided not to accept the resident back. The facility considered the resident discharged due to an extended absence without further communication with the hospital regarding the resident's status or the completion of a Level II PASSAR. The resident's legal guardian was not informed of the facility's decision until contacted to pick up the resident's belongings. The facility's policy required written notification of discharge and notification to the ombudsman, which was not followed in this case.
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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 Cheboygan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mackinac Straits Long Term Care Unit | 21.4 mi | ★★★★★ | 1 | 0 |
| Bay Bluffs-emmet County Medical Care Facility | 27.4 mi | ★★★★★ | 1 | 0 |
| The Villa At The Bay | 30.1 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Rogers City | 34.6 mi | ★★★★★ | 2 | 0 |
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