Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Midland during CMS and state inspections, most recent first.
Delayed Initiation of Anticoagulant Order: A resident with a hx of CVA, aphasia, and rheumatic mitral valve disease returned from a cardiology appt with orders to stop Lovenox and start Eliquis 5 mg BID. The MAR showed Lovenox was discontinued, but the Eliquis order was not entered until 6 days later. The DON could not explain the delay, and later hospital records noted subsegmental PE and treatment with a heparin drip.
An LPN left a syringe of insulin unattended on top of a med cart while a resident was nearby, then opened the cart to reveal preset controlled substances for several residents and a liquid medication for another resident. The LPN said the controlled substances had already been documented as given, even though they were scheduled doses, and the DON observed the medications being emptied into a sharps container without witnessing the waste.
Medication administration records showed multiple doses of metformin, Humalog, Cozaar, and Midodrine were given without required blood sugar or BP checks, or despite values outside ordered hold parameters. An insulin pen for a resident was also kept in use beyond the manufacturer’s 28-day limit, and doses were documented after expiration. The record contained no documentation explaining the out-of-parameter administrations or missed assessments.
Inactive plumbing lines were observed in the kitchen ware washing area and a shower room, including dead-end lines, a faucet handle, and an uncapped pipe. The MD stated the lines were not in use and were not being flushed, and the RMD was unaware of one dead-end line under the clean dish side of the dish machine and said it was not part of the flushing schedule. The facility’s document stated low-flow pipe runs, dead legs, and infrequently used fixtures would be flushed weekly.
Inaccurate and delayed pressure ulcer assessment for a resident with spina bifida and a stage IV left buttock ulcer led to deficient care. The admission nurse identified the wound, but the refusal to assess was not documented, the wound was not measured promptly, and later wound charting failed to accurately reflect the ulcer depth. The RD also documented no skin issues because the wound had not yet been entered in the EMR.
Unsafe Wheelchair Transport: A resident with dementia and anxiety who used a low scoot wheelchair was observed being pushed by a CNA with her feet hanging down and dragging on the floor during multiple transports. A CNA stated footrests should be used to prevent feet from getting tangled, and the DON stated staff are expected to use foot pedals when residents cannot use their feet to move the wheelchair.
A resident with a gastrostomy tube and diagnoses including dysphagia, epilepsy, and a brain malignancy had tube feeding supplies observed in use without the tube feeding bottle or water bag labeled with the resident's name, date, or time started. On a later observation, the TF pump was covered with a pillowcase and running in the dining room, and the water bag in use had been dated more than 24 hours earlier. The DON confirmed the unlabeled supplies and continued use of the outdated water bag.
Failure to replace respiratory equipment timely for two residents with CHF and COPD. One resident had a nasal cannula in use along with a nebulizer mask and tubing that were dated and discolored, while an RN stated respiratory masks and tubing should be changed weekly and the resident had not received a neb treatment for an extended period. Another resident kept a dated nasal cannula in a wheelchair bag and reported using it daily when out of the room. Facility policy required weekly changes for oxygen tubing and mask/cannula and changes to neb tubing and delivery devices every 72 hours.
A resident with a history of stroke, fluid and electrolyte disorders, and a feeding tube had a pharmacy recommendation to add a lipid panel to standing lab orders after atorvastatin was reviewed and approved by the physician. EMR review showed multiple lab draws occurred without a lipid panel being obtained, no lipid panel had been documented since admission, and no pending order was present until a later order was entered; the DON later stated the provider knew the lipid panel was out there, but no documentation showed it had been added before then.
The facility failed to notify responsible parties and family members of medication changes and conditions for two residents, and did not inform medical providers of blood pressures outside established parameters. A resident with dementia and hypertension had multiple medication changes without notifying the designated contact. Another resident with pneumonia was treated without informing the emergency contact. The facility's policy requires notification of significant changes, but documentation was lacking.
A LTC facility failed to follow professional standards for medication administration, resulting in errors for four residents. A resident with diabetes received insulin despite low blood sugar levels, while another with hypertension was given Metoprolol despite low heart rate and blood pressure. Two residents prescribed Gabapentin had discrepancies in their medication records, with doses documented as administered twice without proper documentation. The DON confirmed these errors, indicating a failure to adhere to the facility's medication administration policy.
The facility failed to ensure complete and accurate wound assessments and timely treatments for several residents, leading to deterioration in skin conditions. Inadequate documentation and missed treatments were noted, with staff interviews revealing gaps in the wound management program.
Delayed Initiation of Anticoagulant Order
Penalty
Summary
The facility failed to transcribe and initiate a medication order timely for one resident who had a history of cerebral infarction, aphasia, and rheumatic mitral valve disease. After a cardiology appointment, the resident returned with a consultation form directing that Eliquis 5 mg by mouth twice daily be started and Lovenox be discontinued. The February 2026 MAR showed Lovenox was discontinued on 2/12/2026, but the Eliquis order was not initiated until 2/18/2026, six days later. The resident had previously been discharged from the hospital on twice-daily Lovenox injections for a left peroneal vein DVT and was later switched to Eliquis by cardiology. Facility documentation showed the delay in entering the Eliquis order after the appointment, and the DON stated that when residents return from appointments, consultation sheets are returned to nursing staff for order entry into the EMR, but could not explain why six days elapsed before the Eliquis order was entered. Subsequent records noted the resident later developed subsegmental pulmonary emboli and was treated in the hospital with a heparin drip.
Unsecured and Improperly Handled Medications and Controlled Substances
Penalty
Summary
The facility failed to ensure medications and controlled substances were secured and handled according to policy for four residents. During an observation at 8:12 AM, a plastic cup containing a syringe with clear liquid, a glucometer, and an alcohol swab was left on top of a medication cart with no staff nearby, while an independently ambulatory resident was about 15 feet away. When the LPN returned, he stated the syringe contained insulin for one resident and that he had left it unattended because he had gone to the medication room to obtain another medication not in the cart. The LPN then unlocked the medication cart and revealed three clear plastic medication cups containing pills, which he identified as controlled substances for three residents, along with a clear plastic cup containing a reddish-pink liquid for another resident. He stated the controlled substances had already been documented as given on the MAR, even though the narcotic count showed the doses were scheduled medications and not PRN. The DON observed the preset medications, and the LPN emptied the controlled substances into the sharps container while the DON did not witness the waste. The DON then instructed the LPN on how to document the waste and stated the EMR would need to be corrected to show the medications had not been given as ordered.
Medication Administration Outside Ordered Parameters and Use of Expired Insulin Pen
Penalty
Summary
The facility failed to follow professional standards of nursing practice when medications with ordered hold parameters were administered without first obtaining the required blood sugar or blood pressure assessments, or were given despite values outside the ordered parameters. For Resident #45, who had diabetes, metformin was administered on multiple occasions when the blood sugar was below the ordered hold parameter of 120 mg/dl, including times when the blood sugar was 108, 103, 88, 116, 95, 103, and 93. The record also showed occasions when the evening blood sugar was not assessed before metformin was given, and there was no documentation explaining administration outside the ordered parameters. For Resident #47, who also had diabetes, Humalog was ordered before meals with instructions to hold if blood sugar was less than 120 mg/dl. The record showed Humalog was administered when the blood sugar was 116, 118, 118, 93, and 110, and one dose was documented as not given when the blood sugar was 120. The record also showed an evening dose was administered using a blood sugar result from earlier in the day rather than an assessment at the time of the dose, and there was no documentation explaining administration outside the ordered parameters or the withholding of the dose. For Resident #95, who had heart disease and hypertension, Cozaar was ordered with instructions to hold if systolic blood pressure was less than 120 mmHg. The medication was administered on multiple occasions when systolic blood pressure readings were below 120, including 115, 108, 115, 100, 100, 115, 117, 108, 98, 108, 114, 106, 109, and 115, and on two occasions the blood pressure was not assessed before administration. For Resident #53, who had hypotension, Midodrine was ordered three times daily with instructions to hold if systolic blood pressure was greater than 140. The record showed the medication was administered when the blood pressure was 136/61 and 125/52, and on several occasions the 2:00 PM dose was given without a current blood pressure assessment, using an earlier reading instead. The record also showed no documentation explaining administration outside the ordered parameters or the lack of assessment prior to administration. The facility also failed to follow manufacturer storage and use instructions for Resident #29's Lantus SoloStar insulin pen. A pen labeled for the resident remained in the medication cart beyond the manufacturer's recommended 28-day use period, and the MAR showed the resident received two doses from that pen after the expiration date. The facility policies reviewed stated that medications are to be stored according to manufacturer recommendations and that expired medications are to be identified and reported.
Inactive plumbing lines not included in flushing schedule
Penalty
Summary
The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During a walkthrough of the kitchen with the Maintenance Director, three dead-end lines were observed under the dirty dish side of the ware washing area. Two of the dead-end lines came off the hot water line to the dish machine, and another dead-end line with a faucet handle was closest to the current garbage disposal. When asked what the lines were for, the Maintenance Director stated they were not in use and was unsure what they had been used for or when they were removed from service. He also stated the dead-end lines in the kitchen area were not currently being flushed. In the shower room located between A and B hall, a shower faucet handle and an uncapped pipe coming out of the wall were observed. The Maintenance Director stated the faucet was not in use and the line was not being flushed. When the shower faucet handle was turned on, water came out of the pipe. Review of the Operation Maintenance and Control Limits document, undated, showed the facility would flush low-flow pipe runs, dead legs, and infrequently used fixtures weekly. During a later walkthrough of the kitchen with the Regional Maintenance Director, a dead-end line with a faucet handle under the clean dish side of the dish machine area was observed, and the Regional Maintenance Director stated he was unaware of that line and that it was not part of the flushing schedule.
Inaccurate and Delayed Pressure Ulcer Assessment
Penalty
Summary
The facility failed to accurately assess and measure a stage IV pressure ulcer on the left buttock for a resident admitted with spina bifida and an existing pressure ulcer. The resident’s preadmission wound note dated 7/3/2025 documented the ulcer as measuring 4.4 cm long, 3 cm wide, and 2.2 cm deep. Although the admission nurse identified the wound on 7/7/2025, the wound was not assessed or measured until 7/10/2025. During observation on 8/6/2025, the wound was measured at 2.63 cm long, 3.17 cm wide, and 2.5 cm deep. Wound documentation from 7/10/2025 recorded the ulcer as 4.3 cm long, 2.8 cm wide, with depth documented as not applicable, and documentation from 7/16/2025 recorded it as 2.9 cm long, 2.7 cm wide, and 0.1 cm deep. The wound pictures from both dates clearly showed depth that was not reflected in the measurements. The RN Unit Manager reported the resident refused assessment on 7/7/2025 but did not document the refusal or arrange for timely completion of the wound assessment. The DON also reported the refusal was not documented and stated the wound measurements from 7/10/2025 and 7/16/2025 were believed to be inaccurate. The RD completed a nutrition evaluation on 7/10/2025 and documented no skin issues because the wound had not yet been entered in the electronic record.
Unsafe Wheelchair Transport
Penalty
Summary
The facility failed to provide safe wheelchair transport for one resident with dementia and anxiety who used a low scoot wheelchair for locomotion. During observation, a CNA pushed the resident down the hallway and into her room while her legs were hanging freely and not on foot pedals, and one foot was dragging on the ground. A few minutes later, the same CNA pushed the resident quickly back down the hallway with both feet dragging on the ground. Later, the resident was again observed being pushed in her wheelchair to the dining area for an activity with her legs hanging down and dragging on the floor. In interview, a CNA stated residents should not be pushed in wheelchairs with their feet hanging down and that footrests should be used to prevent accidents from feet getting tangled in the chair. The DON also stated staff are expected to use foot pedals when pushing residents in wheelchairs if the resident is unable to use their feet to move the wheelchair to prevent accidents and injuries from feet getting tangled under the wheelchair.
Tube Feeding and Water Bag Not Properly Labeled or Timed
Penalty
Summary
The facility failed to provide tube feeding according to standards of care for a resident with a gastrostomy tube and diagnoses including malignant neoplasm of the brain, epilepsy, dysphagia, and weakness. The resident was observed in bed with a feeding tube pump next to the bed, a tube feeding bottle connected to the pump, and food visible in the tube. The tube feeding bottle contained approximately 850 ml of a 1000 ml bottle, and a water bag was also connected to the pump. Neither the tube feeding bottle nor the water bag was labeled with the resident's name or the date and time started. On a later observation, the resident's tube feeding pump was covered with a pillowcase and was running in the dining room. The tube feeding was labeled with the resident's name and dated, but the water bag in use had been dated more than 24 hours earlier. Review of the MAR showed the tube feeding had been provided earlier that day, and the DON confirmed the tube feeding and water bag were not dated or labeled when in use and that the outdated water bag had continued to be used beyond 24 hours.
Failure to Replace Respiratory Equipment Timely
Penalty
Summary
The facility failed to ensure timely replacement of respiratory equipment for 2 residents with respiratory diagnoses, including congestive heart failure and chronic obstructive pulmonary disorder. For one resident, observation showed oxygen therapy via nasal cannula dated 7/16 and a nebulizer machine in the room with a nebulizer mask and tubing dated 4/13; the mask and tubing had begun to turn yellow and remained unchanged on a later observation. An RN stated that respiratory masks and tubing should be replaced weekly and reported the resident last received a nebulizer treatment on 6/19/2025. For the second resident, observation and interview showed a nasal cannula dated 6/18 hanging on the back of the wheelchair in a bag, and the resident reported using that oxygen cannula daily when out of the room. Facility policy stated oxygen tubing and mask/cannula should be changed weekly and as needed if soiled or contaminated, and nebulizer tubing and delivery devices should be changed every 72 hours.
Pharmacy Recommendation for Lipid Panel Not Acted Upon
Penalty
Summary
The facility failed to ensure a Pharmacy Recommendation was acted upon for one resident reviewed for pharmacy recommendations. The resident was admitted with diagnoses including cerebral infarction (stroke), disorders of electrolyte and fluid balance, and gastrostomy (feeding tube). A Pharmacy Recommendation dated 6/10/25 noted that atorvastatin was prescribed and requested that a lipid panel be added to the standing lab orders for CBC, CMP, and A1c every six months. The physician checked the agree box and signed the recommendation on 6/12/25. Review of the EMR showed that after the recommendation, the resident had three lab entry dates with results, but no lipid panel was drawn. The EMR also showed that a lipid panel had not been documented since admission, and the Doctor's Orders did not show a pending lipid panel order. On 8/6/25, the DON was interviewed about the pharmacy review and said a review would be conducted. On 8/7/25, the Doctor's Orders were reviewed again and showed a lipid panel order entered into the computer that day. During a later interview, the DON stated she had spoken with the medical provider, who indicated she knew the lipid panel was out there, and the DON provided EMR documentation dated 6/12/25 stating to add the lipid panel to the next standing order lab draw; however, no documentation was identified in the EMR showing the lipid panel had been added before the 8/7/25 lab order.
Failure to Notify Responsible Parties and Providers of Changes
Penalty
Summary
The facility failed to notify responsible parties and family members of changes in medication and condition, as well as failed to notify the medical provider of blood pressures outside of established parameters for two residents. Resident #24, who was admitted with diagnoses including dementia and hypertension, had several medication changes documented in the Electronic Medical Record (EMR) without evidence that the designated Responsible Party (RP) was informed. These changes included the addition of amlodipine for hypertension, an increase in the frequency of Lasix and a potassium supplement, and the administration of Roxanol and Zofran. Additionally, there was no documentation that the RP was informed of a switch from morphine to dilaudid due to a severe allergy. The facility also failed to adhere to its own protocols regarding blood pressure monitoring for Resident #24. Despite education provided to staff on monitoring and reporting vital signs outside of established parameters, the EMR revealed multiple instances of elevated blood pressures without rechecks or documentation that the provider was notified. The Director of Nursing (DON) acknowledged the lack of documentation and indicated that the facility uses a texting system for provider notifications, but no evidence of such communications was provided. For Resident #23, who was cognitively intact and admitted with chronic obstructive pulmonary disorder and dementia, the facility did not notify the designated emergency contact of a pneumonia diagnosis and subsequent treatment with doxycycline. The DON confirmed that the nurse responsible for placing the antibiotic order should have notified the family member and documented the notification, but no such documentation was found. The facility's policy on Notification of Changes requires informing the resident, consulting with the physician, and notifying the family member or legal representative when there is a significant change in the resident's condition.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice for medication administration, resulting in medication errors for four residents. Resident #10, a male with diabetes type II, received insulin despite having blood sugar levels below the physician-ordered threshold of 110 on multiple occasions. This occurred on several dates, including 5/1/24, 5/3/24, 5/7/24, 5/14/24, 5/18/24, 5/22/24, 5/31/24, 6/2/24, and 6/6/24, with blood sugar readings ranging from 62 to 96. Resident #8, a female with hypertension, was administered Metoprolol despite having a heart rate of 50 and a blood pressure of 80/48, both below the physician-ordered parameters. These incidents occurred on 6/3/24 and 6/10/24, respectively. The facility's failure to hold the medication as per the physician's orders led to these errors. Residents #15 and #17, both prescribed Gabapentin, experienced discrepancies in medication administration records. For Resident #15, a dose of Gabapentin was documented as administered twice on 6/9/24, despite the correct amount remaining in the control substance record. Similarly, for Resident #17, doses of Gabapentin were documented as administered twice on 6/2/24, 6/7/24, and 6/8/24, with no documentation of a provider order to hold the medication. The Director of Nursing confirmed these errors, highlighting a failure to follow the facility's medication administration policy.
Inadequate Wound Care Management
Penalty
Summary
The facility failed to ensure complete and accurate pressure injury and wound assessments, as well as the timely ordering and completion of wound treatments for several residents. Specifically, the facility did not conduct thorough assessments or follow the recommendations provided by the Wound, Ostomy, & Continence Nurse for Resident #5, leading to a deterioration of the resident's skin condition from Moisture Associated Skin Damage (MASD) to a stage II pressure injury. Additionally, there was no documentation of notification to the resident's emergency contact about the worsening condition, and the treatment plan was not updated accordingly. For Resident #12, the facility's wound evaluations lacked necessary measurements, such as depth, on multiple occasions, and the wound treatment was not completed as scheduled. Similarly, Resident #13 did not receive a timely wound treatment order upon admission, resulting in missed dressing changes. Resident #14 also experienced incomplete wound evaluations and missed treatments, with no documented rationale for these omissions. These lapses indicate a pattern of inadequate wound management and documentation across multiple residents. The facility's policy on pressure injury prevention and management outlines a systematic approach for assessment, treatment, and monitoring, which was not adhered to in these cases. Interviews with facility staff, including the Nursing Home Administrator and Unit Manager, revealed gaps in the wound management program, such as delays in reconciling treatment orders for new admissions and a lack of audits on ordered treatments. The Director of Nursing confirmed the missed treatments and incomplete assessments, highlighting a failure to meet the facility's own standards and expectations for wound care management.
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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 Midand
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brittany Manor | 5.2 mi | ★★★★★ | 4 | 0 |
| Stratford Pines Nursing And Rehabilitation Center | 6.1 mi | ★★★★★ | 8 | 0 |
| Huron Woods Nursing Center | 16.3 mi | ★★★★★ | 15 | 0 |
| Carriage House Nursing And Rehabilitation | 16.7 mi | ★★★★★ | 1 | 0 |
| Healthsource Saginaw, Inc | 17.3 mi | ★★★★★ | 3 | 0 |
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