Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Green View during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in environmental safety and sanitation, including black slime on an ice machine drain line, damaged and soiled heating register covers in several rooms, and discolored water from a utility room fixture. Maintenance staff acknowledged incomplete cleaning routines and ongoing challenges in obtaining repair parts, resulting in unaddressed issues affecting residents, staff, and visitors.
A resident with severe cognitive impairment was prescribed PRN alprazolam for anxiety, but the physician did not document the clinical rationale or duration of use in the medical record as required. Despite a pharmacist's request and facility policy mandating such documentation for PRN psychotropic medications, the necessary information was not provided.
A resident with a history of Bipolar Disorder and Major Depressive Disorder did not receive a required Level 2 OBRA evaluation after a positive Level 1 PASARR screening. The responsible RN did not refer the case to the CMHSP due to missing documentation from a prior facility, and the Social Services Coordinator did not discuss mental health service options with the resident's representative.
A resident with intact cognition and multiple health conditions experienced two falls due to an improperly secured mobility bar, resulting in a concussion and a hip fracture. The facility failed to repair the mobility bar after the first fall, despite recognizing it as a contributing factor. The Director of Nursing missed the issue in incident reports, and the Maintenance Director confirmed a broken spring in the bar. The facility's policy required a physician's order for bed rails, which was not present.
A facility failed to respect a resident's preference for medication administration location, providing medications in the dining room instead of the resident's room. The RN did not observe the resident taking the medications, and the resident expressed a preference for receiving medications in her room. The DON confirmed that such preferences should be documented in the care plan, highlighting a deficiency in respecting resident rights and dignity.
A resident with a spinal fracture was not assisted by staff in donning a required TLSO back brace, despite a physician's order and care plan. The resident, who was cognitively intact, reported being unable to put on the brace independently since therapy ended. The Treatment Administration Record inaccurately showed the brace was applied daily, and staff interviews revealed a lack of proper assistance, contrary to facility policy.
The facility failed to document the rationale for declining GDR for an antipsychotic medication for a resident and did not document the rationale and duration for PRN use of a psychotropic medication for another resident. The medical records lacked necessary documentation, and interviews with staff confirmed the absence of required information. The facility's policy on psychotropic drug use and GDR was not followed.
A facility failed to follow infection control practices during medication administration for two residents. An RN handled a water cup and medications with bare hands, and adjusted a straw without gloves before administering them to residents. The DON confirmed these actions as infection control issues, violating facility policies.
Environmental Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, functional, sanitary, and comfortable environment. On several occasions, areas within the facility were found to be unclean or in disrepair. Specifically, the drain line on the ice machine in the main dining room was noted to have black slime growing on the end of the pipe, and the Maintenance Director confirmed that while the ice machine and drain tray are cleaned weekly, the drain line itself is not. Additionally, several heating register covers in resident rooms were found to be damaged, loose, or improperly attached, with some exposing heating coils and others accompanied by soiled and splattered walls. The register in one room was described as 'beat up' by a resident's guardian/conservator, who also noted its poor appearance. Further inspection revealed that the soiled utility room's hopper produced brown, discolored water when first turned on, which cleared only after a clog was dislodged. The Senior Maintenance Director stated that this fixture had not previously been included in the regular flushing schedule but would be added going forward. Multiple rooms in the A Wing were found to have heat register covers that were either damaged or not fully attached, with visible debris and exposed heating elements. The Maintenance Director indicated ongoing difficulty in obtaining parts needed for repairs, resulting in continued deficiencies in the physical environment.
Lack of Physician Documentation for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the physician documented the clinical rationale and duration of use for a PRN (as needed) psychotropic medication prescribed to a resident with severe cognitive impairment. The resident was admitted with a diagnosis requiring psychotropic medication, specifically alprazolam for anxiety, but the Minimum Data Set (MDS) assessment did not indicate any coded behaviors. The electronic medical record showed that the PRN alprazolam order was initiated and continued, but there was no documentation from the physician regarding the clinical rationale or the intended duration of use for this medication. A pharmacist's medication regimen review specifically requested that the attending physician evaluate the diagnosis, behaviors, and usage patterns, and to document the rationale and duration for the PRN order, as required by facility policy. Despite this, the physician did not provide the necessary documentation in the resident's medical record. The facility's policy states that PRN psychotropic orders should not exceed 14 days unless the prescriber documents their rationale and the duration for continued use, which was not done in this case.
Failure to Complete Required PASARR Level 2 Evaluation for Resident with Mental Illness
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with diagnoses of Bipolar Disorder and Major Depressive Disorder received the required Level 2 OBRA (Omnibus Budget Reconciliation Act) evaluation following a positive Level 1 PASARR (Preadmission Screening and Resident Review) screening. The resident's electronic medical record showed an admission date and documented recent treatment for mental illness, including the use of psychotropic medications. Despite these findings, there was no evidence in the medical record that a Level 2 evaluation was completed or that the Level 1 screening was referred to the Community Mental Health Services Program (CMHSP) as required. Interviews with facility staff revealed that the MDS Nurse, responsible for PASARR completion, did not send the Level 1 assessment to the CMHSP because the necessary documentation was not transferred from the resident's previous facility. As a result, the nurse did not receive notification to follow up with the local CMHSP. Additionally, the Social Services Coordinator confirmed that the resident was not receiving mental health services and that the resident's representative had not been approached regarding the option to accept or decline such services. The facility's policy required notification to the state's PASARR program for a Level 2 screen when indicated, but this process was not followed in this case.
Failure to Secure Mobility Bar Leads to Resident Falls
Penalty
Summary
The facility failed to ensure a mobility bar was properly fixated to a bed frame for a resident, resulting in two separate falls. The resident, who had intact cognition and a history of chronic obstructive pulmonary disease, right foot amputation, and depression, experienced a fall on 5/30/24. During this incident, the mobility bar was not locked, causing it to swing out of place, which contributed to the fall. The resident suffered a closed head injury and was sent to the emergency room for evaluation. A second fall occurred on 6/19/24, where the resident was found on the floor with injuries to her right forearm and knee, and complained of severe pain. The fall resulted in a nondisplaced fracture of the greater trochanter of the right femur, requiring surgical intervention. The mobility bar was again identified as a contributing factor, as it was not locked in place, allowing the resident to roll out of bed. Interviews with staff revealed that the mobility bar was not repaired after the first fall, despite being recognized as a predisposing factor. The Director of Nursing admitted to missing the issue in the incident reports, and the Maintenance Director confirmed a broken spring in the mobility bar. The facility's policy required a physician's order for bed rails, which was not present in the resident's medical record, and emphasized the importance of proper installation and maintenance of bed rails to prevent such incidents.
Failure to Respect Resident's Medication Administration Preferences
Penalty
Summary
The facility failed to ensure that medications were administered in an environment of the resident's choosing, which is a violation of the resident's rights. During an observation of medication administration, a Registered Nurse (RN) provided a resident with her prescribed medications while she was eating breakfast in the dining room with other residents. The RN placed the medications directly on the table next to the resident and left the dining room without observing the resident take the medications. This action was not in accordance with the resident's preference, as the resident later stated that she usually receives her medications in her room and expressed a clear preference for this to continue. The Director of Nursing (DON) confirmed that medications should not be administered in the dining room unless the resident prefers it, and such preferences should be documented in the care plan. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of respecting resident rights and individuality, including the right to privacy in treatment and care. The failure to adhere to these policies and the resident's expressed preferences resulted in a deficiency in the facility's care practices.
Failure to Assist Resident with Required Back Brace
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as R20, in donning a Thoracolumbosacral orthosis (TLSO) back brace, which was required for spinal support following a fracture. Observations on two consecutive days revealed that the TLSO was not being worn by R20, despite a physician's order and care plan indicating it should be worn when out of bed. R20, who was cognitively intact and did not refuse care, reported that she could not put on the brace by herself and had not received assistance since her skilled therapy ended in July. The Physical Therapist Assistant confirmed that R20 required help with the brace and that nursing staff were responsible for assisting her after therapy services concluded. The Treatment Administration Record inaccurately indicated that the TLSO was applied daily, with no documented refusals from R20. However, RN A, who signed the record, admitted to not assisting R20 and assumed that CNAs were responsible for applying the brace. Interviews with the Director of Nursing and other staff confirmed that the expectation was for nursing staff to assist R20 with the TLSO. The facility's policy on the use of assistive devices emphasized the need for staff to provide appropriate assistance, which was not adhered to in this case.
Failure to Document Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to document the rationale for declining gradual dose reductions (GDR) for an antipsychotic medication for one resident. The resident was prescribed Abilify for bipolar disorder and hallucinations, but no attempts at GDR were documented since the resident's admission. A form indicating a GDR was contraindicated was incomplete, lacking the physician's rationale. Interviews with staff confirmed the absence of documentation and involvement from the facility's contracted psychiatric services, as the resident was followed by Community Mental Health, which also lacked documentation in the medical record. Additionally, the facility did not document the rationale and duration for the PRN use of a psychotropic medication for another resident. This resident was prescribed lorazepam PRN for anxiety, but the medical record did not contain adequate indications for use or a physician's rationale for the PRN order. A Medication Regimen Review by the consultant pharmacist highlighted the need for documentation, but the physician's response was not adequately recorded in the medical record. Interviews with the Director of Nursing revealed that non-pharmacological interventions like melatonin were attempted but deemed ineffective, yet continued to be administered. The DON could not provide a rationale for using an antianxiety medication instead of a hypnotic for sleep assistance. The facility's policy required documentation of rationale and duration for PRN orders, which was not adhered to in these cases.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for two residents. During an observation, a registered nurse (RN) was seen preparing medications for a resident without using gloves. The RN picked up a plastic water cup by the lip with ungloved hands, poured water into it, and placed it on the resident's bedside table without a barrier. When the resident attempted to take the medications, some fell onto the bed. The RN picked up the medications with bare fingers and returned them to the medication cup, which the resident then used to take the medications. In another instance, the same RN administered medications to a different resident and adjusted a straw with bare hands before placing it into the resident's mouth. These actions were confirmed as unacceptable by the Director of Nursing, who acknowledged them as infection control issues. The facility's policies on infection prevention and medication administration require the use of barriers and avoiding direct contact with medication and surfaces, which were not adhered to in these instances.
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What surveyors actually found near you
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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 Alpena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Alpena | 0.7 mi | ★★★★★ | 8 | 0 |
| Medilodge Of Hillman | 21.6 mi | ★★★★★ | 29 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 28 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Rogers City | 29.4 mi | ★★★★★ | 2 | 0 |
| Jamieson Nursing Home | 30 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.