Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Gaylord during CMS and state inspections, most recent first.
Food storage and sanitation practices were not followed for multiple items in the dietary dept and pantry. Surveyors found opened frozen foods and thickened beverages that were unlabeled, undated, or past use-by dates, and a sanitizer bucket with a wiping cloth tested at zero parts chlorine, indicating no sanitizer.
A resident with sepsis due to MSSA, osteomyelitis, and a PICC line was observed under Contact Precautions, but staff entered the room and provided care without the required gown and gloves despite a posted CDC sign. The Infection Preventionist also confirmed several IPCP-related policies had not been reviewed annually, and staff described Contact Precautions and EBP as basically the same.
Medication administration errors resulted in a 19% error rate, including one resident receiving only one oxycodone tablet when two were ordered and several late doses for other residents. RN B also delayed PEG tube feedings and flush preparation, and one resident’s tubing was observed improperly stored. The DON stated meds should be given within 1 hour before or after the scheduled time and orders should be double checked.
Unlabeled and expired medications were found in two medication carts. An expired Humalog vial, an undated Symbicort inhaler, and several undated ophthalmic medications for two residents were observed, and staff were unsure of the correct dating requirements. The A-hall cart also contained loose pills and debris in a drawer, and the DON stated the carts were supposed to be cleaned weekly.
Lack of Order and Care Plan for Indwelling Urinary Catheter: A resident with an indwelling urinary catheter was observed multiple times with the catheter drainage bag dragging on the floor and collecting dust while being propelled in a wheelchair. The resident’s record lacked a physician order for the catheter and had no care plan, interventions, goals, care, or monitoring documented. The DON stated the expectation was to have an order with catheter size, care plan interventions, and monitoring.
Respiratory care was not provided as ordered for multiple residents. One resident who required continuous oxygen had no physician order for supplemental O2, was observed with the nasal cannula displaced, and had no documented respiratory assessments with ordered nebulizer treatments. Two other residents had nebulizer equipment stored improperly with condensation present, and during treatments the RN was not in the room while the residents were unattended; in both cases, the nebulizer mask became displaced from the tracheostomy and a CNA intervened.
Incomplete Arbitration Agreement Process: A resident who was cognitively intact had an ALTERNATIVE DISPUTE RESOLUTION AGREEMENT that was electronically signed, but most required initials were missing and the acknowledgement that he understood and voluntarily entered the agreement was not initialed. The resident later stated he probably did not understand the paperwork and so did not sign it, while staff and the NHA agreed the contract was not completed in full.
Missing Hospice Communication and Documentation: The facility failed to document and coordinate hospice services for a resident receiving hospice care. An RN said she only knew hospice had visited when told, and the DON could not find records of hospice visits, services provided, progress notes, or planned visits in the hospice binder or medical record. The NHA also could not locate the documentation, and the facility policy required communication and documentation of hospice interventions and plan-of-care coordination.
Failure to Offer Eligible Flu and Pneumococcal Vaccinations: The facility did not ensure that two residents were offered indicated pneumococcal and influenza vaccines. One resident with stroke, asthma, dementia, and dysphagia had a pneumococcal vaccine due, and another resident with CHF, vascular dementia, and PVD was overdue for pneumococcal and seasonal influenza vaccines. The IP confirmed both residents had not yet been offered their eligible immunizations per facility policy.
Failure to Offer Eligible COVID-19 Vaccinations: The facility failed to offer the COVID-19 vaccine to two residents whose MCIR records showed the vaccine was due or overdue. One resident had stroke, asthma, dementia, and dysphagia; the other had CHF, vascular dementia, and PVD. Their EMRs did not show the vaccine had been offered, and the IP confirmed both residents had not yet been offered their eligible immunizations per facility policy.
A resident with chronic conjunctivitis and MRSA in the left eye experienced months of worsening symptoms, including redness, purulent drainage, pain, crusting, and swelling, while the facility failed to act on a provider’s ophthalmology referral and did not timely schedule a specialty eye appointment. A provider documented a referral for ophthalmology after minimal response to treatment, but no corresponding order appeared in the EMR, and the former scheduler reported likely never being informed of it amid ongoing issues with missed orders. Nursing notes over subsequent months repeatedly described persistent and escalating signs of infection, yet an ophthalmology appointment was not ordered "ASAP" until much later, and the eye clinic confirmed the first contact from the facility occurred only shortly before the resident was finally sent by EMS. By the time the resident was evaluated, outside providers documented a months-long history of worsening eye infection and diagnosed severe ocular infection with sepsis, and later observations still showed left eye swelling and blurred vision.
A resident on hospice with lung cancer, COPD, vertebral fracture, and post-laminectomy syndrome became unable to eat, drink, or swallow, yet continued to receive lorazepam oral tablets as documented on the MAR. After an episode where the resident reportedly choked when a tablet was given with water, nursing staff began dissolving lorazepam tablets into atropine solution without a corresponding provider order to change the medication form. An RN stated this was customary practice for end-of-life care, while the consulting pharmacist reported that dissolving a tablet into another medication’s solution is not standard practice and that a liquid lorazepam formulation exists. The DON referenced supposed standing orders allowing medications to be crushed and dissolved, but later the DON and NHA acknowledged that no such standing orders policy existed.
A resident admitted with lung cancer, vertebral fracture, post-laminectomy syndrome, COPD, and urinary retention did not receive multiple first doses of ordered medications for pain, BPH, nausea/vomiting, and airway patency because the drugs were documented as "on order" and not yet available. A complainant reported the resident waited a significant time for physician orders and missed initial doses. The DON acknowledged that delays in prescriptions and limited back-up stock could lead to missed doses and that discharge orders were not always available before arrival, despite policies requiring immediate-care medication orders and timely pharmacy services with 24/7 emergency coverage.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to properly store and dispose of expired medications and did not maintain accurate temperature logs for the medication refrigerator. Observations revealed expired supplements, improperly dated vaccines, and medication carts with undated insulin pens and inhalers. An unlocked medication cart was found unattended with loose pills and an unidentified pill container. Staff interviews indicated a lack of awareness and adherence to medication storage policies.
The facility failed to implement an effective IPCP, lacking a designated IP and relying on external personnel for infection control. The MDS nurse, RN D, was unable to provide comprehensive information about infection tracking and monitoring. Specific cases, such as a resident with a persistent respiratory infection and two residents testing positive for COVID-19, highlighted the deficiencies. Additionally, infection control policies were not updated annually, and the DON acknowledged the problem.
The facility did not employ a qualified Infection Preventionist (IP) to manage the Infection Prevention and Control Program (IPCP). The DON admitted that infection control was managed by someone from another building, and RN D, the MDS nurse, lacked training and knowledge about infection control policies. The facility's policy required a qualified IP to coordinate and manage the IPCP onsite.
The facility failed to provide written transfer notifications to residents, their representatives, and the LTC Ombudsman for four residents transferred to the hospital. The medical records lacked documentation of the required notifications, and the binder meant to hold these notices was empty for two months. Administrative staff confirmed the inconsistency in receiving necessary information from nursing staff, leading to the deficiency.
The facility failed to provide written notice of the bed hold policy to four residents or their representatives during hospital transfers. Medical records lacked documentation of the policy issuance, and Administrative Staff F confirmed inconsistencies in maintaining notifications. The facility's policy required timely notification, which was not adhered to in these cases.
A facility failed to maintain resident privacy by leaving a medical cart computer open, displaying a resident's Physician Orders, and a visible 'Controlled Substance Log'. This breach was confirmed by the DON, who stated that the information should have been securely locked and closed.
A resident with severe cognitive impairment and incontinence was not provided appropriate care for Moisture Associated Skin Damage (MASD) as per professional standards. The resident was found soaked in urine and had scratched herself, leading to blood under her fingernails. The facility staff failed to document check and change procedures consistently, and record sheets were improperly shredded, contrary to the facility's policy.
The facility failed to provide proper respiratory care for three residents by not following physician orders and infection control protocols. A resident had a nasal cannula that was not changed weekly, and incorrect oxygen settings were noted on a Bipap machine. Another resident's nasal cannula was undated, and there were no clear parameters for oxygen flow rate. Additionally, respiratory equipment for a third resident was improperly stored and undated. The DON admitted to not being trained on proper procedures, and facility policies were not adhered to.
The facility failed to manage medications properly for two residents, leading to deficiencies in administration and documentation. A resident received Lorazepam after discontinuation, with discrepancies in the eMAR and controlled substance log. Another resident's Alprazolam lacked a required stop date. The DON confirmed that discontinued medications should be removed promptly, and medications should not be dispensed without a physician's order.
A facility failed to document non-pharmacological interventions before administering PRN anxiolytics to a resident with dementia, administered an antipsychotic without a documented indication, and did not consider a GDR for an antidepressant. The DON confirmed the lack of documentation, and the NHA acknowledged the absence of a GDR, contrary to facility policy.
A facility failed to maintain accurate wound documentation for a resident with skin failure, leading to inconsistencies in the classification and staging of wounds. Staff interviews revealed that management instructed the wound care nurse to classify pressure injuries as 'Other' due to the resident's diagnosis, resulting in potential ineffective treatment plans. The MDS Coordinator confirmed that comprehensive assessments relied on EMR documentation, which inaccurately reflected the resident's condition.
The facility did not post daily nurse staffing information, as required, leading to outdated information being displayed. The Staffing Coordinator was absent, and nursing staff were responsible for posting but did not do so due to confusion with the form. The NHA was aware of the requirement but noted the form's lack of user-friendliness.
Two residents with cardiac and respiratory conditions did not receive timely and comprehensive assessments at an LTC facility. One resident, post-heart surgery, lacked vital sign monitoring upon admission and experienced a decline, leading to death. Another resident with chronic heart issues had delayed cardiac evaluations and insufficient monitoring for orthostatic hypotension, resulting in multiple falls and eventual death. Staffing shortages and incomplete documentation contributed to these deficiencies.
Food Storage and Sanitizer Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for all 70 residents living in the facility. During a dietary department tour with the RD and DM, surveyors observed multiple food items in the reach-in freezer that were either opened and unsealed or partial bags that were unlabeled and undated, including beef patties exposed to air, frozen formed cookie dough, frozen premade biscuits, and frozen hashbrowns. The reach-in refrigerator also contained opened thickened apple juice with an opened date of 1/28 and a use-by date of 2/3. Additional observations in the C Hall pantry found opened quart containers of honey thickened orange juice, nectar thickened cranberry juice, and thickened cranberry juice that were missing required opened dates and/or use-by dates. In the dietary department reach-in refrigerator, two containers of honey thickened milk were marked opened 3/10/26 with a use-by date of 3/16/26, which was two days past the use-by date at the time of observation. The facility policy required all foods stored in the refrigerator or freezer to be covered, labeled, and dated, and the report also noted a sanitizer bucket with a wiping cloth floating in the solution that tested at zero parts chlorine, indicating no sanitizer.
Failure to Follow Contact Precautions and Review IPC Policies Annually
Penalty
Summary
The facility failed to ensure correct implementation of transmission-based precautions for Resident #87, who was admitted with diagnoses including sepsis due to MSSA and osteomyelitis of the left ankle and foot. On 3/17/2026, the resident was observed self-propelling in a wheelchair toward his room without a protective gown, even though a CDC Contact Precaution sign was posted on the door and PPE was staged in the hallway. The sign directed staff to put on gloves and a gown before room entry. Later that day, an LPN entered the resident’s room without donning a gown or gloves, despite the contact precaution sign still being posted, and provided care including preparing IV antibiotics, assisting the resident into bed, removing his sweatshirt, and accessing and flushing his PICC line without wearing a protective gown. The report also states the facility did not ensure infection prevention and control policies were reviewed annually. The Infection Preventionist confirmed that several IPCP-related policies had not been updated within the required annual timeframe, including the Infection Prevention and Control Program, Infection Surveillance, Antibiotic Stewardship Program, Influenza Vaccination, and Pneumococcal Vaccine (Series) policies. The Infection Preventionist stated the resident was placed in Contact Precautions due to an infection in his spine and said staff were to wear a gown and gloves for high-contact care activities, while also stating that Contact Precautions and Enhanced Barrier Precautions were basically the same. The facility policy required an annual review of the infection prevention and control program and associated policies and procedures.
Medication Administration Errors and Late Doses
Penalty
Summary
The facility failed to ensure accurate and timely medication administration for four residents, resulting in 5 errors out of 26 opportunities and a medication error rate of 19%. During observation of medication passes, RN B administered oxycodone 5 mg to one resident but gave only one tablet when the MAR ordered two tablets every 6 hours for pain. The same resident also received methocarbamol 500 mg. RN B later stated she had only given one oxycodone, acknowledged she should have given two, and then asked the resident if he wanted the second tablet. Additional errors involved late administration of ordered treatments and medications for three other residents. One resident received PEG tube feeding and a water flush 30 minutes late, and RN B delayed preparing water for the flush for over 15 minutes before taking water from her pitcher. Another resident received PEG tube feeding more than an hour late, and the resident’s Mickey tubing was observed lying on a bedside table on paper towels rather than stored in a zip lock bag. A third resident received enoxaparin and midodrine late, with the enoxaparin scheduled for 9:00 AM and the midodrine scheduled for 1:00 PM. The DON stated medications should be given no sooner than an hour before and no longer than an hour after the scheduled time, and nurses should double check medication orders for accuracy.
Unlabeled and Expired Medications Found in Medication Carts
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles in two medication carts reviewed. In the D-Hall medication cart, an opened multi-dose Humalog U-100 vial for Resident #57 was found without a protective cap, with an open date of 2/14/2026 and an expiration date of 3/14/2026; RN R confirmed the vial was expired and should have been removed from active medication supply. The same cart also contained an open Symbicort inhaler with no written date showing when it was opened or when it would expire, and RN R confirmed there was no dating on the inhaler or its storage box and was unsure whether it had a shortened expiration date after opening. A clear plastic bag in the medication cart contained Resident #63’s erythromycin ophthalmic ointment, moxifloxacin ophthalmic solution, and polymyxin B sulfate/trimethoprim ophthalmic solution, but none of the medications had an open date or expiration date written on them. RN R reported the DON had instructed staff that no open or expiration date was needed because there was enough preservative in the solution to keep it good. The DON later reviewed manufacturer information and found shortened expiration periods for the moxifloxacin and polymyxin B sulfate/trimethoprim ophthalmic solutions, while stating she could not find a reference for the erythromycin ointment. In addition, the A-hall medication cart contained loose Baclofen and Carvedilol tablets and medication particles and paper debris in the bottom of a drawer; the NHA and DON both observed the dirty cart, and the DON stated the carts were to be cleaned weekly.
Lack of Order and Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide an order, care plan interventions, and goals for one resident with an indwelling urinary catheter, Resident #58, out of two residents reviewed for indwelling catheters. On 3/17/26, R58 was observed sitting in a wheelchair in the hallway with the urinary catheter drainage bag attached beneath the seat touching the floor and dragging on the floor when the wheelchair was propelled. On 3/18/26, R58 was again observed self-propelling his wheelchair down the hall with the catheter bag dragging on the floor inside a privacy bag, and the privacy bag had visible dust on the front, sides, and back. During interview, a CNA stated the bag should not be dragging on the floor collecting dust. Review of the resident’s order summary from 9/17/26 through 3/18/26 showed no physician orders for an indwelling urinary catheter. The medical record also lacked any order for the catheter, as well as any care plan, interventions, goals, care, or monitoring related to the catheter. The DON stated her expectation for a resident with an indwelling urinary catheter was to have an order indicating the size, care plan interventions, and monitoring. The facility policy stated indwelling urinary catheters are to be used in accordance with physician orders and that the care plan addresses the use of the catheter, including strategies to prevent complications.
Respiratory Care Deficiencies with Oxygen Orders, Nebulizer Assessments, Equipment Storage, and Supervision
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents receiving oxygen and nebulizer treatments. For Resident 36, the electronic medical record contained a care plan for impaired pulmonary/respiratory status and an intervention for oxygen as ordered, but there was no physician order for supplemental oxygen. The resident was observed with a nasal cannula below the chin and later with the cannula in only one nostril, while also having audible crackles with inspiration and intermittent coughing. The Director of Nursing confirmed that a physician order was required for oxygen and that the resident was expected to have continuous supplemental oxygen delivery. Resident 36 also had an order for albuterol sulfate nebulizer treatments three times daily, but the LPN administering the treatment did not complete respiratory assessments before or after the treatment. Review of the MAR, TAR, and RAR showed respiratory assessments were not documented before or after the three daily nebulizer administrations in March 2026. The DON stated that respiratory assessments, including SpO2, should be completed with each nebulizer treatment, and the record review confirmed they were not completed as expected. For Residents 80 and 13, nebulizer equipment was observed stored with the tubing and mask connected in a bag with visible condensation in the medication cup. The Unit Manager/RN stated the equipment should be taken apart, rinsed, left to dry, and then stored separately. During nebulizer treatments for both residents, the RN was not present in the room and the residents were unattended. For Resident 80, the nebulizer mask was not properly positioned on the tracheostomy and a CNA adjusted it; for Resident 13, the mask became unattached from the tracheostomy and a CNA reattached it. The RN later acknowledged failing to supervise the resident and to rinse and store the equipment properly.
Incomplete Arbitration Agreement Process
Penalty
Summary
The facility failed to explain and obtain an acknowledgement of understanding for a binding arbitration agreement for one resident. R10 was interviewed in his room and stated he remembered nothing regarding an arbitration agreement. The electronic medical record showed he was admitted as his own responsible party, and the MDS assessment indicated a BIMS score of 15 out of 15, showing he was cognitively intact. R10’s ALTERNATIVE DISPUTE RESOLUTION AGREEMENT was reviewed and the final page had been electronically signed, but 12 of the 20 points in the contract required initials and only one of those blanks had been initialed. Point number 19, stating that the signer had fully read, understood, and was voluntarily entering into the agreement and had an opportunity to ask questions before signing, had not been initialed by R10. During interviews, the acting admission director stated she was not present for the paperwork, and the NHA and Business Office Manager reviewed the agreement and agreed it was not completed in full. When R10 was asked again about the paperwork, he stated, "I probably did not understand it and so I did not sign it."
Missing Hospice Communication and Documentation
Penalty
Summary
The facility failed to ensure communication and documentation occurred for coordination of care for hospice services provided to one resident, who was admitted with hospice services and was documented in the MDS, resident roster, and care plan as receiving hospice care. The care plan identified a hospice focus for the resident with a terminal prognosis and end-of-life diagnosis, but the record reviewed did not contain documentation showing how hospice and the facility communicated regarding the resident’s care. During interviews, an RN stated she had no idea how hospice communicated with the facility and was only told when hospice personnel had been there. The DON reviewed the hospice binder for the resident and found only one care plan, with no documentation of hospice visits, progress, care provided, or planned future visits. Signature sheets were present but did not list resident names, and the DON could not determine the hospice service frequency, when hospice staff were last present, what services had been provided, or when the next visits were scheduled. The NHA also could not locate the documentation and agreed hospice collaboration was missing. The facility policy stated it would maintain written agreements and communicate, follow, and document interventions and maintain communication with hospice regarding the resident’s plan of care and services.
Failure to Offer Eligible Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure eligible residents were offered influenza and pneumococcal vaccinations as recommended by the CDC for 2 of 5 residents reviewed for vaccination status. Resident #12 was admitted with diagnoses including cerebral infarction (stroke), moderate persistent asthma, dementia, and dysphagia. Review of the Michigan Care Improvement Registry showed the resident’s pneumococcal vaccination was due now, but the electronic medical record did not show that the resident had been offered the pneumococcal immunization. Resident #87 was admitted with diagnoses including CHF, vascular dementia, and peripheral vascular disease. Review of the Michigan Care Improvement Registry showed the resident was overdue for PCV15/PCV20/PCV21 and seasonal influenza vaccination, with influenza overdue since 10/1/25, but the electronic medical record did not show that the resident had been offered either the pneumococcal or influenza immunization. During interview, the Infection Preventionist verified responsibility for the infection prevention and control program, including the vaccination program, and confirmed that both residents had not yet been offered their eligible immunizations per facility policy.
Failure to Offer Eligible COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure eligible residents were offered the COVID-19 immunization as recommended by the CDC for 2 residents reviewed for vaccination status. Resident #12 was admitted with diagnoses including cerebral infarction (stroke), moderate persistent asthma, dementia, and dysphagia. Review of the Michigan Care Improvement Registry showed the COVID-19 2025-26 vaccine was due now, but the resident's EMR did not show that the vaccine had been offered. Resident #87 was admitted with diagnoses including CHF, vascular dementia, and peripheral vascular disease. Review of the Michigan Care Improvement Registry showed the COVID-19 2025-26 vaccine was overdue, with an overdue date of 8/27/2025, and the EMR did not show that the vaccine had been offered. During interview, the Infection Preventionist verified responsibility for the vaccination program and confirmed that both residents had not yet been offered their eligible immunizations per facility policy, stating the facility was working to get caught up.
Failure to Act on Ophthalmology Referral and Coordinate Timely Eye Care
Penalty
Summary
The deficiency involves the facility’s failure to act upon a provider’s ophthalmology referral and to timely coordinate specialty eye care for one resident with a chronic and worsening left eye infection. The resident had a history of schizoaffective disorder, morbid obesity, and prior stroke, with moderately impaired decision-making requiring cues and supervision. In early April 2025, a physician documented bilateral eye irritation and redness consistent with conjunctivitis. On 5/13/2025, an NP/PA documented chronic conjunctivitis and ordered a culture of the left eye drainage before starting antibiotics. A physician order dated 5/17/2025 directed staff to obtain the left eye drainage culture that day, and the 5/22/2025 bacteriology report showed 3+ MRSA in the eye culture. On 6/26/2025, a physician progress note documented continued management of conjunctivitis with recent treatment having no to minimal effect and indicated that new orders and an ophthalmology referral were given. However, review of the EMR showed no corresponding physician order for an ophthalmology referral at that time. The facility’s own staff later acknowledged that the 6/26/2025 referral was not found in the EMR and that there had been an ongoing issue with missed orders around that period. The former scheduler stated he likely was not informed of the June referral, and the Unit Manager/RN stated she was unsure where in the process the June referral broke down, but confirmed that the ophthalmology appointment was not attempted to be scheduled until months later. During the months following the June referral, nursing documentation showed persistent and progressively worsening signs and symptoms of left eye infection. Between early July and mid-September, multiple infection/signs and symptoms notes described green mucus drainage at the inner canthus, crusting despite cleansing and eye drops, bilateral eye redness with drainage, ongoing redness with drainage, repeated scleral injection, increased redness, tenderness, and purulent drainage, the eye being closed shut with thick yellow drainage and pain, and swelling around the eye. On 9/15/2025, a physician order was entered for an ophthalmology appointment “ASAP” related to chronic eye infections. The ophthalmology clinic later confirmed that the first contact from the facility to schedule this resident was not until 9/25/2025, despite the clinic’s ability to see acute eye pain cases within about three days. When the resident was finally transported by EMS to the ophthalmology clinic, staff there documented a months-long history of red, irritated eye with purulent discharge, worsening pain and redness, and immediate concern for bacterial cellulitis and possible sepsis, leading to referral to an ER. The ER documented septic shock and severe eye infection, and the specialty hospital discharge summary confirmed preseptal cellulitis, bacterial keratitis of the left eye, and sepsis present on admission. At the time of the surveyor’s observations in February 2026, the resident’s left eye remained swollen, limiting visualization of the eye and partially blocking vision, and the resident reported that vision in the left eye was still “a little blurry.” The facility’s DON could not explain why there were two separate ophthalmology referrals, one in June and one in September, and acknowledged uncertainty about what happened with the earlier referral. The Unit Manager/RN described the facility’s process as requiring that referrals be transcribed into the EMR as orders so that the transport driver can schedule appointments, but confirmed that the June referral was missed. The ophthalmology clinic’s receptionist confirmed that the facility did not contact the clinic about this resident until late September, despite the chronic and worsening eye condition documented over the preceding months.
Improper Alteration and Administration of PRN Lorazepam at End of Life
Penalty
Summary
The deficiency involves the facility’s failure to administer a medication in the prescribed form for one resident receiving end-of-life care. The resident was admitted with diagnoses including malignant neoplasm of the lung, vertebral fracture, post-laminectomy syndrome, COPD, and urinary retention. Documentation in the EMR showed that nursing staff noted the resident was not drinking or eating and was on hospice, and later documented that the resident could no longer swallow. Despite these entries, the Medication Administration Record showed that lorazepam oral tablets continued to be administered multiple times after it was documented that the resident could no longer eat, drink, or swallow. During interviews, the complainant reported that near the end of the resident’s life, he was unable to swallow and that a nurse attempted to give a tablet with water, which caused the resident to choke. The complainant further stated that after this, staff dissolved the resident’s pills in other medication liquids to form a solution. The nurse who provided care confirmed that she dissolved lorazepam tablets into atropine solution to administer the medication and stated she did not believe a physician’s order was needed to change the form of the medication, indicating this was a common practice for end-of-life residents. The facility’s pharmacy consultant stated it was not standard practice to dissolve a tablet into another medication’s solution and noted that lorazepam is available in a liquid formulation. The DON initially stated that standing orders allowed medications to be crushed and dissolved into another medication unless contraindicated, but later the DON and NHA acknowledged the facility did not have a standing orders policy.
Failure to Ensure Timely Availability of Admission Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure prescribed medications were readily available for a newly admitted resident, resulting in multiple missed first doses. The resident was admitted with diagnoses including malignant neoplasm of the lung, T7–T8 vertebral fracture, post-laminectomy syndrome, COPD, and urinary retention. Physician orders dated for the admission included Morphine Sulfate ER 30 mg (2 tablets every 12 hours for cancer-related pain), Flomax 0.4 mg at bedtime for benign prostatic hyperplasia related to urinary retention, Prochlorperazine 10 mg every 8 hours for nausea/vomiting related to lung cancer, and Budesonide-Formoterol 160/4.5 mcg (2 puffs every 12 hours) for COPD-related airway patency. Review of the MAR showed that the evening dose of Morphine ER, the bedtime dose of Flomax, the evening and next-morning doses of Prochlorperazine, and the evening dose of Budesonide-Formoterol on the first days after admission were not administered, with the reason documented as “on order.” During a telephone interview, the complainant reported that the resident waited a significant amount of time for physician orders and missed the first dose of several medications as a result. In an interview, the DON stated that depending on the medication, it was not uncommon to have a delay in prescriptions arriving at the facility, which could result in a missed dose, and explained that the facility maintained only a limited back-up supply and that controlled substances could be delayed if there were issues getting the physician’s order to the pharmacy. The DON also stated that the facility did not always have discharge orders before the resident arrived. Facility policies reviewed indicated that admission orders must include medication orders for immediate care and that the provider pharmacy was required to provide routine and timely pharmacy service, including 24/7 emergency service.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all forms of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these types of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to properly store and dispose of expired medications and did not maintain accurate temperature logs for the medication refrigerator. During an observation, a registered nurse was unaware of the requirement to check refrigerator temperatures, and it was found that temperature logs were incomplete or missing for several months. Additionally, expired therapeutic nutrition powder supplements were found in the medication room, and multi-use vials of vaccines were not properly dated after being opened. Further inspection of medication carts revealed several issues, including insulin pens and inhalers that were opened without expiration dates, loose pills that were not identified, and a pill container without a resident's name. One medication cart was found unlocked and unattended, with loose pills and an unidentified pill container inside. The staff responsible for these carts were either unaware of the need to date medications or admitted to forgetting to lock the cart. Interviews with nursing staff and the Director of Nursing highlighted a lack of awareness and adherence to the facility's policies regarding medication storage and handling. The Director of Nursing acknowledged that medications should be dated when opened, medication carts should be regularly cleaned, and refrigerator temperatures should be checked twice daily. However, these practices were not being consistently followed, leading to the deficiencies observed during the survey.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program (IPCP), which resulted in the potential spread of infectious organisms and disease to all 82 residents. The Director of Nursing (DON) admitted that the facility did not have a designated Infection Preventionist (IP) and relied on someone from another building to manage infection control information. The MDS nurse, RN D, who had some training in infection prevention, was unable to provide comprehensive information about the IPCP, including tracking and monitoring of infections. The IPCP binder for December 2024 was empty, and RN D was unaware of how infections were documented or tracked. Specific cases highlighted the deficiencies in the IPCP. A resident was prescribed Doxycycline for a respiratory infection, but the symptoms persisted, and the same antibiotic was re-prescribed without apparent effectiveness. RN D was unfamiliar with the infection control policies and did not know the details of the infection cases or the testing procedures for other residents. Additionally, the facility's infection control policies, including those for vaccinations, had not been updated annually as required. The DON acknowledged the problem with infection control in the facility.
Lack of Qualified Infection Preventionist in Facility
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was employed at least part-time and present to manage the Infection Prevention and Control Program (IPCP). During an interview, the Director of Nursing (DON) admitted that the facility did not have an IP and that someone from another building, who was not employed at the facility, was handling infection control information. The DON indicated that a Registered Nurse (RN) D, who was the MDS nurse, had training in infection prevention and control, but any questions regarding the IPCP should be directed to RN D. However, during an interview with RN D, it was revealed that RN D was unable to answer questions about the processes for identifying, monitoring, tracking, correlating, reporting, documenting, and controlling infections and communicable diseases within the facility. RN D stated that they primarily handled MDS and had never been trained on the infection control policies, indicating a lack of knowledge about the infection control program. The facility's policy required a qualified individual to be designated as the IP, whose primary role was to coordinate and be accountable for the IPCP, including the antibiotic stewardship program, and to work onsite at the facility.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written transfer notifications to residents, their representatives, and the Office of the State Long-Term Care Ombudsman for four residents who were transferred to the hospital. The medical records for these residents did not indicate that written notifications of transfer, including the reason, effective dates, and the location to which the residents were being transferred, were given. This deficiency was identified for four out of seven residents reviewed for transfers out of the facility. The residents involved were transferred to the hospital and readmitted without the required documentation being provided to them or their representatives. Administrative Staff F confirmed that the written notifications of bed holds and transfers were not maintained as expected. The binder, which was supposed to contain these notifications, was found to be empty for the months of November and December. Staff F stated that it was inconsistent whether she received the necessary information from the nursing staff, and no written transfer notices were sent for the residents on the ombudsman log for those months. The facility's Transfer Discharge Policy required that transfer notices be provided as soon as practicable, but this was not adhered to, leading to the deficiency.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to four residents or their representatives when they were transferred to the hospital. This deficiency was identified during a review of the medical records for these residents, which revealed that no documentation of the bed hold policy issuance was present. Specifically, the records for residents transferred on various dates throughout the year did not include the required notifications, indicating a lapse in the facility's adherence to its own Transfer Discharge Policy. Administrative Staff F confirmed that the written notifications of bed holds and transfers were not maintained as expected. The staff member stated that the notifications were supposed to be filed in a binder organized by month, but the months of November and December were empty. Staff F acknowledged that the process was inconsistent, as notifications were not always received from the nurses. The facility's policy required that the bed hold policy be provided to the resident and their representative at the time of transfer or within 24 hours, but this was not followed in the cases reviewed.
Breach of Resident Privacy Due to Unsecured Medical Information
Penalty
Summary
The facility failed to maintain the personal privacy of medical information for one of the four hallways reviewed. During an observation, the D-hall medical cart computer was found with an open display showing the Physician Orders for a resident, making the information visible to unauthorized individuals. Additionally, a 'Controlled Substance Log' for the same resident was clearly visible on the cart. This breach of privacy was confirmed by the Director of Nursing, who acknowledged that the computer display and documentation should have been securely locked and closed.
Inadequate Care for Resident with MASD
Penalty
Summary
The facility failed to provide appropriate care for a resident with Moisture Associated Skin Damage (MASD) according to professional standards of practice. The resident, who was admitted with diagnoses including cerebral infarction, neurogenic bladder, and type 2 diabetes, was found to have severe cognitive impairment and was always incontinent of bowel and bladder. Observations and interviews revealed that the resident was not being checked and changed every two hours as required, leading to the resident being found soaked in urine and scratching herself, resulting in blood under her fingernails. The resident's Durable Power of Attorney (DPOA) reported these issues, which were supposed to be addressed in the care plan. The facility's staff failed to document the check and change procedures consistently in the electronic medical record (eMAR), and the record sheets were being shredded at the end of each day, contrary to the facility's policy. The Director of Nursing (DON) confirmed that staff should document every check and change in the eMAR and that the destruction of record sheets was not in line with the facility's procedures. The facility's incontinence policy stated that all residents who are incontinent should receive appropriate treatment and services to prevent infections, which was not adhered to in this case.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents by not adhering to physician orders and infection control protocols. Resident #331 was observed with a nasal cannula that had not been changed since 12/3/24, despite physician orders requiring weekly changes. Additionally, the resident's Bipap machine had a note indicating incorrect oxygen settings, and the nebulizer mask was improperly stored and undated. Resident #330's nasal cannula was undated, and there were no clear parameters for oxygen flow rate, leaving nurses without guidance on adjusting oxygen levels. Licensed Practical Nurse B confirmed the lack of parameters and the improper storage and dating of respiratory equipment. Resident #43 also had improperly stored and undated respiratory equipment, with a nebulizer and nasal cannula left unbagged and without a barrier. The Director of Nursing admitted to not being trained on the proper procedures but acknowledged the standard practice of weekly changes and proper storage. The facility's policies on oxygen administration, nebulizer therapy, and CPAP/BiPAP support were not followed, leading to deficiencies in the care provided to these residents.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to properly manage pharmaceutical services for two residents, leading to deficiencies in medication administration and documentation. For one resident, a prescribed antianxiety medication, Lorazepam, was not reevaluated after 14 days as required by regulation, and doses were administered after the medication had been discontinued. Additionally, the medication was not signed out on the electronic medication administration record (eMAR) on multiple occasions, and the controlled substance log did not match the eMAR entries. The discontinued medication remained in the narcotic controlled lock box for approximately three months, contrary to the facility's policy that requires timely removal of discontinued medications. Another resident was prescribed Alprazolam without a discontinuation date, which is against the regulation that requires a stop date after 14 days for PRN psychotropic drugs. The Director of Nursing confirmed that controlled substances should be removed promptly once discontinued and that medications should not be dispensed without a physician's order. The facility's policies on medication destruction, controlled substance administration, and medication administration were not adhered to, resulting in these deficiencies.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented before administering as-needed anxiolytic medication to a resident with severe cognitive impairment and multiple diagnoses, including dementia and depression. The resident was given diazepam on multiple occasions without any record of attempted non-pharmacological interventions, as confirmed by the Director of Nursing (DON). This lack of documentation hinders the physician's ability to make informed decisions about the resident's medication regimen and affects the staff's ability to revise the care plan effectively. Another deficiency was identified in the administration of an antipsychotic medication to a resident without a documented diagnosis or indication for its use. The resident, admitted for therapy services following hospitalization for a cutaneous abscess, was prescribed Seroquel for sleep without any psychotic-related issues noted in the medical record. The DON and Regional DON were unable to provide a reason for the medication's use, highlighting a failure to review and justify the medication regimen as per the facility's policy. Additionally, the facility did not consider a gradual dose reduction (GDR) for an antidepressant medication prescribed to a resident with major depressive disorder. The resident's care plan indicated a risk for psychosocial well-being alterations, yet there was no documentation of GDR attempts or contraindications in the social service progress reviews. The Nursing Home Administrator acknowledged the absence of a GDR for the medication, which is contrary to the facility's policy requiring GDR attempts within the first year of admission or after initiating a psychotropic medication.
Inaccurate Wound Documentation for Resident with Skin Failure
Penalty
Summary
The facility failed to maintain accurate wound documentation for a resident receiving hospice care, resulting in an inaccurate reflection of the resident's condition. The resident, identified as having skin failure, was observed with a large dark purple area on the right hip, indicative of a deep tissue injury. The Licensed Practical Nurse (LPN) reported the resident had three wounds, but the classification of these wounds was inconsistent with the documentation in the electronic medical record (EMR). The EMR showed discrepancies in the classification and staging of the wounds, with some wounds documented as 'Other - Not Set' instead of being accurately classified as pressure injuries. Interviews with staff revealed that the facility's regional management instructed the wound care nurse to classify the resident's hip wounds as 'Other' due to the diagnosis of skin failure, despite the wounds being pressure injuries. The Certified Wound and Ostomy Nurse confirmed the importance of accurate wound assessments for effective treatment planning. However, the nurse admitted to changing the wound classification based on management's direction, which led to the potential for ineffective treatment plans due to incorrect documentation. Further interviews indicated that clinical staff were sometimes directed to avoid documenting pressure injuries for residents with a diagnosis of skin failure. The MDS Coordinator confirmed that comprehensive assessments relied on the EMR documentation, and if wounds were not documented as pressure injuries, they would not be included as such in the assessments. This practice resulted in the inaccurate communication of the resident's medical condition to healthcare providers, potentially affecting the continuity of care and the formulation of effective interventions.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of nurse staffing information, which resulted in the inability of residents, their representatives, and visitors to determine the number of staff available to provide resident care. On December 15, 2024, the Daily Nurse Staffing Form was observed to be outdated, showing a date of December 12, 2024, three days prior to the observation. During an interview, the Staffing Coordinator, Staff A, reported that she was responsible for completing and posting the daily staffing levels but had not worked from December 13 to December 16, 2024. In her absence, the nursing staff were responsible for this task. The Nursing Home Administrator acknowledged awareness of the requirement for daily posting and indicated that the nursing staff did not complete the staff posting due to the form being not user-friendly and causing confusion.
Inadequate Cardiac and Respiratory Assessments Lead to Resident Deaths
Penalty
Summary
The facility failed to ensure comprehensive and timely cardiac and respiratory assessments for two residents with cardiac and respiratory conditions. Resident 1, who had a history of heart surgery, heart failure, and other cardiac issues, was admitted to the facility but did not receive vital sign monitoring upon arrival. The resident's cardiac and respiratory assessments were delayed, with the first comprehensive assessment occurring two days after admission. During the resident's stay, there was a lack of communication between nursing and therapy staff regarding vital signs, and the resident's condition deteriorated, leading to their death without timely intervention. Resident 2, who had a history of atrial fibrillation, ventricular tachycardia, and chronic heart failure, also experienced inadequate monitoring. The resident's cardiac evaluation was completed four days after admission, and there was a lack of comprehensive vital sign monitoring, particularly for orthostatic hypotension, which was a known issue for the resident. The resident experienced multiple falls and low blood pressure episodes, which were not adequately addressed or documented, leading to their eventual death from cardiac arrest. The report highlights systemic issues within the facility, including staffing shortages and incomplete documentation, which contributed to the lack of timely and comprehensive assessments for both residents. The facility's failure to carry over hospital discharge orders, such as the use of compression stockings for Resident 1, further exacerbated the situation, leading to preventable complications and ultimately the deaths of both residents.
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 13 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 Gaylord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Munson Healthcare Otsego Memorial Hospital Ltcu | 0.5 mi | ★★★★★ | 11 | 0 |
| Grandvue Medical Care Facility | 24.6 mi | ★★★★★ | 2 | 0 |
| Munson Healthcare Crawford Continuing Care Center | 25.5 mi | ★★★★★ | 7 | 0 |
| Meadow Brook Medical Care Facility | 26 mi | ★★★★★ | 9 | 0 |
| The Villa At The Bay | 26.4 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.