Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Tawas City during CMS and state inspections, most recent first.
Failure to supervise residents with repeated falls: Two residents with significant fall histories, including dementia, impulsivity, weakness, and prior head injuries/fractures, continued to fall in the facility. Staff described keeping a close eye on one resident who would get up, run, and fall, while the other resident had multiple bed, wheelchair, and unwitnessed falls with lacerations, skin tears, and fractures. The DON acknowledged more fall-prevention interventions could be needed, and the facility did not report one fracture-related fall because the resident said she was her own person.
Infection control practices were not consistently followed. Staff were observed providing care to a resident on EBP while wearing only gloves, entering a contact precaution room without PPE, and moving between residents without hand hygiene. Hallway sanitizer dispensers were empty after a recall, staff were not given individual sanitizer, and a med tech used gloves and then sanitizer from a med cart after leaving a resident room. Infection surveillance records were also inaccurate, with mismatched infection counts, missing organism data, and unclear classification of resident and staff infections.
Failure to operationalize the Antibiotic Stewardship Program occurred when the facility treated multiple residents for UTI and other infections without clear organism identification, culture and sensitivity results, or documentation that McGeer criteria were met. The IC RN could not confirm whether infections met criteria, and antibiotic tracking reports only listed medications rather than showing whether treatment was appropriate. One resident continued cephalexin despite no growth on UA/C&S, another received Macrobid without an identified organism, and a third had antibiotic therapy started from a positive UA with no C&S in the record. A resident also returned from the ER with UTI treatment and later had the antibiotic changed, while the organism remained unavailable in the facility record.
Failure to Identify Organisms Before Treating UTIs: The facility treated multiple residents for UTI with antibiotics, but for several residents the record lacked a urine C&S or identified organism. An Infection Control Preventionist stated the facility did not obtain a C&S for some cases and, for others, had not yet obtained the organism from the outside provider or hospital. One resident with severe cognitive impairment received sequential antibiotics after an ER visit, another with moderate cognitive impairment and frequent urinary incontinence was treated with Macrobid after a positive culture for E. coli, and the facility’s antibiotic stewardship policy required lab testing per standards of practice.
Safe medication storage was not maintained for two residents. One resident had a cup of multiple pills left at the bedside even though the resident had not been assessed for self-medication administration, and the assigned nurse was not immediately available. Another resident on the dementia unit had an open bottle of antifungal powder left in the room with no top, despite being severely cognitively impaired and totally dependent for ADLs.
Care plan not updated after repeated falls and injuries. A resident with multiple falls, including unwitnessed and floor-found events with fx of the wrist and pelvis and later a head laceration requiring sutures, had no new interventions added to the fall/injury care plan after the latest injury. The DON reviewed the record and confirmed the care plan did not reflect the resident’s changing care needs.
Failure to identify skin breakdown led to worsening skin issues for three residents. One resident with Parkinson’s disease and limited mobility developed buttock skin damage with wet briefs, bleeding, and non-blanchable erythema. A second resident had fragile skin with open, bleeding areas in the buttocks and thigh region that were still being treated as MASD. A third resident had painful groin redness with peeling skin, a strong yeast odor, and a soaked brief, but the issue had not been recognized earlier by nursing staff.
PICC Line Care Not Performed Using Sterile Technique A resident with a LUE PICC for IV ABT had observed breaks in care during flushing and dressing change. An LPN did not check for blood return or use a pulsatile push/pause flush, and an RN did not maintain sterile technique during the dressing change, touched the insertion site with clean gloves, handled sterile supplies improperly, left the site uncovered while obtaining supplies, and attempted to measure arm circumference directly over the uncovered insertion site.
A resident with COPD, sleep apnea, and chronic respiratory failure was observed receiving oxygen by NC, but the prongs were on the cheek instead of in the nose. The oxygen was set at 2.5 L/min even though the HCP order was for 2 L NC at night, and the tubing was dated well beyond the weekly change schedule ordered for oxygen tubing and filters. RN and LPN staff stated the tubing should be changed weekly, and the DON confirmed oxygen should be administered per order.
Improper backflow prevention was observed on multiple water connections. In the kitchen, an overhead spray nozzle was found below the flood rim in the garbage disposal, and on exterior spigots, hoses had spray nozzles attached downstream of hose bib atmospheric vacuum breakers. Staff stated the kitchen sink and spray nozzle were being replaced and that the hoses normally do not have spray nozzles attached.
A facility failed to comprehensively assess and implement a care plan for a resident with a history of inappropriate sexual behaviors and a law enforcement-ordered tether. Staff were not informed of the resident's criminal history, leading to concerns about safety, especially with children visiting the facility. The lack of communication and assessment hindered the creation of a meaningful care plan.
The facility failed to provide timely assistance with ADL care, including showers and hygiene, for several residents, leading to unmet needs and complaints. Observations noted issues like unkempt hair and unshaven faces, despite care plans indicating the need for regular assistance. Residents with conditions such as dementia and cognitive impairment were affected, highlighting a lack of adherence to the facility's ADL policy.
The facility failed to provide palatable meals, leading to complaints from four residents about dry yams and soggy bread. A resident had to cut off the top of a dry sweet potato, while another found their yam dried and bread soggy from ham juice. The CDM stated that yams were baked without butter or oil, and bread was placed directly on the plate. Another resident experienced soggy bread from baked beans, highlighting issues with meal preparation.
The facility failed to maintain a sanitary kitchen and proper food handling practices, as observed during a walkthrough and dining task. Expired food items were found, and kitchenware had dried food particles. A dietary staff member served food without proper hand hygiene, using gloves that had touched their hips. These deficiencies risk foodborne illness for 71 residents.
The facility failed to maintain a clean and homelike environment in the memory care unit, where a strong urine odor was present due to a carpet that was frequently soiled by residents. Staff interviews revealed dissatisfaction with the carpet choice, as it required daily cleaning and detracted from other duties. The facility's policy to minimize odors was not upheld, leading to unsanitary conditions.
A facility failed to include a PTSD diagnosis in a resident's admission assessment, as noted on the CMS 802 form. The resident, admitted for respite care, had a documented history of PTSD, COPD, and dementia. This oversight was identified during an annual recertification survey, and the correct diagnosis was only recorded after the surveyor's observation and interview with the MDS assessment nurse.
A facility failed to create a comprehensive care plan for a resident with COPD, dementia, and PTSD, who required oxygen therapy at bedtime and assistance with ADLs. The resident reported not receiving regular showers, and the care plan lacked specific days for bathing. Additionally, the care plan did not include interventions for oxygen therapy or monitoring of nighttime oxygen saturation levels, leading to the likelihood of unmet needs.
A resident with COPD requiring nighttime oxygen therapy was admitted to the facility without receiving the necessary oxygen for four days. The facility's referral process failed to ensure the administration of oxygen as per the resident's needs, and the care plan lacked interventions for monitoring nighttime oxygen saturation levels. Staff interviews revealed that the oversight occurred during the admission process.
The facility failed to maintain cleanliness and sanitation of medication and treatment carts, with three medication carts and one treatment cart found in unsanitary conditions. Crushed medications, loose pills, and dried shampoo drippings were observed, indicating a failure to adhere to the facility's Medication Storage policy. The night shift was responsible for cleaning the carts, but deficiencies in medication management and storage practices were evident.
The facility failed to provide meals according to the preferences and dislikes of two residents, resulting in decreased food intake and frustration. One resident did not receive the tomato soup and grilled cheese listed on their meal ticket, while another did not receive the cottage cheese indicated. The CDM acknowledged the oversight and cited a supply issue for the missing cottage cheese. Additionally, a resident's breakfast meal was left untouched due to a dislike of eggs, which was noted on their meal ticket.
A CNA in an LTC facility was reported by multiple residents and staff for being rude, rushed, and disrespectful, leading to anxiety and frustration among residents. The facility failed to adequately document and address these grievances, resulting in a deficiency in care standards.
The facility failed to follow professional standards for medication administration, affecting six residents. Errors included administering medications outside physician-ordered parameters, not signing out controlled substances, and failing to assess vital signs before administering certain medications. These actions led to discrepancies in medication records and non-compliance with facility policies.
A facility failed to appoint a legal guardian for a resident deemed incompetent to make medical decisions, despite the resident's severe cognitive impairment and dementia. The resident had a financial conservator but no medical guardian, and the facility did not arrange for guardianship despite policy requirements. Interviews confirmed the lack of communication and action regarding the resident's guardianship status.
A resident with a history of spinal issues experienced an unwitnessed fall and complained of back pain. The facility failed to conduct a comprehensive assessment or timely notify a physician, resulting in a delay in diagnosing an acute T11 spinal fracture. The resident's pain worsened, and she was eventually sent to the ER, where the fracture was identified.
Failure to Supervise Residents With Repeated Falls
Penalty
Summary
The facility failed to ensure that residents were adequately supervised to prevent falls. The report identified repeated falls for two residents, including one resident with dementia, severe confusion, unsteadiness, muscle weakness, cognitive communication deficit, and a history of repeated falls, and another resident with repeated falls and head injuries. Staff interviews described both residents as impulsive or prone to getting up, running, or falling, and staff stated they were to keep a close eye on them or provide one-on-one supervision at times. For the resident with dementia, the record showed multiple falls in the facility, including a witnessed fall in the dining area where the resident was running and tripped, a fall from a wheelchair, a fall while standing in the day room after a shower, a fall while ambulating in the hall, and a fall next to the bed that was caught by a CNA. The resident was observed with dried blood over the left eyebrow and was unable to be interviewed because of decreased cognition and communication deficit. Facility notes and hospital records showed injuries including an eyebrow laceration requiring repair, an abrasion to the nose, and prior head injuries. Staff stated the resident was not supposed to get up and that they kept a close eye on her because she would walk and run but was now unsteady. For the other resident, the record showed repeated falls with injury, including a fall from bed with a head laceration requiring sutures, an unwitnessed fall in the room, a witnessed fall from the bed with a head laceration and skin tear, and a witnessed fall when the resident toppled forward from the bed while sitting unattended. The resident also had earlier falls with fractures of the wrist and pelvis, and the emergency department record described the resident being sent from the nursing home after a slip and fall with those fractures. The resident was observed lying in bed in the dark and complained of headache, and the DON acknowledged there could be more interventions for prevention of falls. The report also stated that the facility did not report the fall with fractures because the resident was her own person and told the facility what happened.
Infection Control Program Not Implemented Consistently
Penalty
Summary
The facility failed to implement and operationalize its infection prevention and control program, including transmission-based precautions, hand hygiene access, PPE use, and infection surveillance/data tracking. During observation, a sign outside one resident’s room indicated Enhanced Barrier Precautions were in place, but the resident was found awake in bed with pants and bedding visibly saturated with urine while a CNA provided care wearing only gloves. A med tech later entered the same resident’s room wearing PPE, and staff were observed not consistently understanding or applying the required precautions for residents on EBP or contact precautions. A second resident had Contact Precautions for an MRSA right shoulder abscess and IV antibiotics, yet staff interviews showed confusion about why the precautions were in place and when PPE was required. An activity aide did not know why the resident was on Contact Precautions, and a CNA stated PPE was worn only when touching the resident, not when simply entering the room or retrieving something. The resident also stated that not all facility staff wore PPE when entering the room. On another observation, a CNA entered the contact precaution room without PPE, picked up the resident’s oxygen tubing from the floor without gloves or other PPE, exited the room, and then entered another resident’s room without performing hand hygiene. Hand hygiene supplies were not readily accessible throughout the facility. Multiple hallway hand sanitizer dispensers on different units were observed empty, and the nurse educator confirmed the dispensers were empty because the sanitizer had been recalled. Staff were not provided individual hand sanitizer bottles, and the explanation given was that staff were supposed to wash their hands in resident rooms, even though some rooms shared bathrooms. During medication pass, a med tech removed gloves after administering eye drops, walked into the hallway without hand hygiene, attempted to use an empty hallway dispenser, then used sanitizer from the medication cart after documenting the medication administration. The DON acknowledged the staff member should have washed hands in the resident bathroom. The infection control surveillance and data review process was also inaccurate and inconsistent. The infection control nurse was unable to reconcile discrepancies between the line list, mapping tool, and monthly analysis for October 2024 and June 2025, including mismatched infection counts, missing organism information, and incorrect classification of infections as HAI, CAI, prior, or NA. The nurse also could not identify the staff member associated with a COVID outbreak, explain why COVID was not listed on the line list, or clarify several resident infection entries, including one resident with MRSA-related treatment and inconsistent admission and onset dates. Facility policies reviewed stated that hand hygiene must occur before and after glove use, PPE must be used as appropriate, and the infection prevention and control program must include surveillance for all residents, staff, volunteers, visitors, and other individuals.
Failure to Operationalize Antibiotic Stewardship and Document Culture-Based Treatment
Penalty
Summary
The facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program, including documentation and treatment review for residents receiving antimicrobial therapy. During interview and record review, the Infection Control RN stated the facility used McGeer criteria, but the monthly antibiotic line listings and monthly analysis did not specify whether infections being treated met those criteria. The Infection Control RN also stated that the computer system identified whether an infection met McGeer criteria when entered, but she was not sure whether any listed infections did not meet criteria, and the antibiotic use report provided to the prescriber was only a list of antibiotics prescribed during the month. For one resident, the October 2024 line list showed a healthcare-associated UTI with cephalexin treatment, but the causative organism was not identified. The Infection Control RN stated she did not know whether the infection met McGeer criteria. When asked about the urinalysis and culture, she stated there was no growth, yet the antibiotic was continued, and she could not provide documentation that the antibiotic use was addressed with the health care provider. The same resident was also listed for a new infection in October and was treated with daptomycin for MRSA involving a dialysis port, with the line list noting that the resident was to receive IV vancomycin and daptomycin at dialysis. The Infection Control RN stated the wound culture and causative organism were most likely in hospital records and were not readily available in the facility's infection control tracking. For another resident, a urology visit note documented hematuria and UTI with an order for Macrobid 100 mg twice daily for 30 capsules, and the MAR showed Macrobid was given for 15 days for UTI. The facility's antibiotic line listing identified the organism as 'Null.' The Infection Control RN stated the urologist office did not identify an organism and the facility did not perform a culture and sensitivity. For a third resident, progress notes documented a positive UA and a new order for Macrobid 100 mg twice daily for 5 days, but no organism was identified and no culture and sensitivity was found in the medical record. The resident later complained of loose stools, which were documented as a side effect of antibiotic medication. The Infection Control RN stated the antibiotic was started with no organism known and that there were no risk versus benefit statements for residents because she was unsure what to do when antibiotic use occurred without an identified organism. A fourth resident was sent to the ER for chest pain and shortness of breath and returned with a UTI diagnosis and antibiotic therapy. The Infection Control RN stated the organism still needed to be obtained from the ER or hospital, and no urine culture or sensitivity was found in the medical record at the time of review. The resident's MAR showed cephalexin for UTI, later changed to ciprofloxacin. The Infection Control RN acknowledged that treating the wrong organism could create antibiotic-resistant organisms. The facility policy stated that the Antibiotic Stewardship Program was intended to optimize infection treatment while reducing adverse events associated with antibiotic use, and that laboratory testing should follow current standards of practice and narrow-spectrum antibiotics should be used whenever possible.
Failure to Identify Organisms Before Treating UTIs
Penalty
Summary
The facility failed to prevent facility-acquired urinary tract infections for 4 sampled residents, including residents #31, #35, #44, and #70. Record review and interviews showed that each resident received antibiotic treatment for a UTI, but the medical record did not contain a urine culture and sensitivity or identified organism for several of the cases. The Infection Control Preventionist stated that for residents #31, #35, and #44, the facility did not have an organism identified in the record and no culture and sensitivity was found at the time of survey review. Resident #31 was noted to have hematuria and a UTI at a urology visit and was ordered Macrobid 100 mg twice daily for 30 capsules, with the facility MAR showing a 15-day course. The Infection Control Preventionist stated the urologist office did not identify an organism and the facility did not do a culture and sensitivity. Resident #35 had a positive urinalysis and was started on Macrobid 100 mg twice daily for 5 days, but no organism was identified in the progress notes and no culture and sensitivity was found in the medical record. Resident #44, who had severe cognitive impairment and diagnoses including atrial fibrillation, hypertension, renal insufficiency, malnutrition, and stroke, was treated for a UTI after an ER visit with Keflex 500 mg three times daily, later changed to Cipro 250 mg twice daily, while the Infection Control Preventionist stated the organism and culture still needed to be obtained from the hospital. Resident #70 had moderate cognitive impairment and required partial/moderate assistance with toileting hygiene. The resident was on a check-and-change program and had 50 documented urine incontinence episodes out of 57 entries during the look-back period. The resident was treated with Macrobid 100 mg twice daily for 7 days after a urinalysis and culture were positive for E. coli, with symptoms of burning with urination, discomfort, and odor. The facility’s antibiotic stewardship policy stated laboratory testing should follow current standards of practice and narrow-spectrum antibiotics should be used whenever possible.
Medication Storage and Self-Administration Lapses
Penalty
Summary
The facility failed to ensure safe medication storage for two residents when medications and biologicals were left in resident rooms instead of being secured or directly observed during administration. For one resident, a clear cup containing multiple pills was observed sitting on a bedside dresser next to a cup of water. The resident stated the nurse had left the medications there for them to take, and also said that some nurses leave medications in the room while others stay and watch the resident take them. At the time of the observation, the assigned nurse could not be located in the hallway or at the nurses’ station. For that resident, MDS RN N later confirmed the cup contained eight pills and stated the resident had not been assessed for self-medication administration. The medications were identified as carbidopa-levodopa, digoxin, doxycycline, fluoxetine, Actos, acidophilus, glipizide, and diltiazem ER. The resident’s record showed diagnoses including left femur fracture, diabetes mellitus, surgical infection, and Parkinson’s disease, and the MDS described the resident as moderately cognitively impaired and needing supervision to total assistance with ADLs except eating. The MAR showed the medications were ordered to be given together daily at 8:00 AM and had been documented as administered that morning. For the second resident, who was totally dependent for ADLs, on hospice, and on the locked dementia unit with severe cognitive impairment, an open bottle of Nystin powder with no top was observed sitting on a windowsill in the resident’s room. Several residents were walking around the unit, and the resident was observed walking in the hallway by herself. The physician order directed application of house fungal powder every shift to a red area under the left breast and belly button until resolved. During interview, RN M stated the bottle top should have been on and the medication should not have been left in the resident’s room.
Care plan not updated after repeated falls and injuries
Penalty
Summary
The facility failed to update and revise Resident #9’s individualized, person-centered care plan to reflect changing care needs after repeated falls and injuries. Resident #9 was identified on the CMS-802 Resident Matrix as having a fall with injury, and during observation and interview she stated she had fallen at her closet, had a broken arm from the fall, and had tailbone pain. She was observed lying in bed with the privacy curtain pulled so she could not be seen from the doorway, and on another observation she was again lying in bed with the curtain pulled between beds and not visible from the hallway. She was later observed sitting outside in a wheelchair appearing asleep and leaning to the left. Record review and interview with the DON showed multiple falls, including an unwitnessed fall on 3/4/2025 when Resident #9 was found on the floor by a CNA and later sent to the ER, where x-rays showed a fractured wrist and pelvis. She also had a fall on 4/22/2025 when she was found on the floor between her bed and wheelchair, and a fall on 7/4/2025 when she was found on the floor on her stomach with a laceration to the left side of her head, was not wearing footwear, complained of dizziness, and received 2 sutures in the ER. Review of the care plans with the DON showed no new interventions were added to the fall/injury care plan after the 7/4/2025 head laceration fall, despite the repeated falls and injuries documented in the record.
Failure to Identify and Address Skin Breakdown
Penalty
Summary
The facility failed to identify skin breakdown for three residents, which resulted in a lack of timely implementation of interventions to prevent further skin injury. Resident #3, who was non-ambulatory related to Parkinson’s disease, used a wheelchair and spent a lot of time in bed. Record review showed a new moisture associated skin damage finding on 8/28/2025 with open skin areas to both buttocks and scabs, and later observations found a wet, soiled brief with strong urine odor, bleeding on the brief, and open, fragile areas along the buttock cleft. The wound care nurse later identified three new areas of concern on the buttocks region and documented deterioration with non-blanchable erythema and intermittent aching pain. Resident #13 reported thin, fragile skin on her bottom and groin with several little sores that were open, damp, and uncomfortable. Her skin assessment showed moisture associated skin damage with measurements on 9/2/2025. During observation, the resident was found with open areas on the rear left thigh and five small open areas with bleeding into the brief, and she complained of discomfort when the areas were touched. The wound care nurse stated that bleeding would mean the area was an open wound and that the resident’s classification had not yet been changed. Resident #70 was observed with an odor of yeast and later reported that his groin was sore and painful, stating the whole area was on fire and that no cream had been provided. Observation of the peri area showed redness on both sides of the groin and behind the scrotum with peeling skin edges and a wet, soaked brief. The DON and CNA observed the redness, and the wound care nurse later documented a smelly yeast-like rash with flaky edges that was spreading and notified the physician for new orders.
PICC Line Care Not Performed Using Sterile Technique
Penalty
Summary
The facility failed to ensure proper PICC line care for a resident who had a left upper extremity PICC line inserted for IV antibiotic therapy related to MRSA infection of the right shoulder/arm. The resident’s record identified the IV access as a PICC line, and the care plan included interventions for IV catheter care, maintenance, dressing changes, and IV medications/flushes per orders. The resident was observed with a reddened PICC insertion site and a dressing dated several days earlier, while the order required transparent dressing changes every 7 days and as needed. During observation of the PICC line being disconnected and flushed, an LPN did not check for blood return and did not use a pulsating or push/pause flushing method. The LPN stated they believed blood return was only checked before administering antibiotics and said they were not taught to use a pulsating flush, only a slow flush. The PICC line clamp itself was inscribed with instructions to check blood return and flush. During the PICC dressing change, the RN did not maintain sterile technique. The RN removed the StatLock securement device with clean gloves and touched the insertion site, handled sterile kit items while not wearing sterile gloves, discarded the sterile drape, and had to leave the insertion site uncovered while obtaining additional supplies after the sterile gloves broke and the securement device malfunctioned. The RN also attempted to measure the arm circumference by placing the measuring tape directly over the uncovered PICC insertion site, and the exposed site touched the resident’s upper body during the procedure. The facility policy required sterile gloves for dressing changes, and the referenced infusion standards included use of sterile gloves when touching the insertion site and measurement of arm circumference when clinically indicated.
Oxygen tubing not changed per order and nasal cannula found displaced
Penalty
Summary
The facility failed to ensure that respiratory care and oxygen therapy tubing were changed according to the HCP order for Resident #2. The resident was admitted with diagnoses including infection, rheumatoid arthritis, PTSD, and COPD, and the MDS indicated moderate cognitive impairment with need for assistance with ADLs. The care plan addressed impaired pulmonary/respiratory status related to COPD, sleep apnea, chronic respiratory failure, and frequent removal of oxygen, with interventions for oxygen as ordered and oxygen as needed when signs or symptoms of difficulty breathing were present. On observation, Resident #2 was found with supplemental oxygen via nasal cannula, but the cannula prongs were positioned on the resident’s cheek rather than in the nose. The resident stated the tubing must have come out while brushing hair and said they did not wear oxygen at home but had been wearing it around the clock at the facility. The oxygen concentrator was set at 2.5 L/min, while the HCP order specified oxygen at 2 L NC at night for sleep apnea and COPD. The tubing had a date sticker of 8/24, despite the order for oxygen tubing and filter changes every week. RN M, LPN U, and the DON all stated the tubing should be changed weekly, and RN M said nursing staff should also check the tubing, but the tubing remained dated 8/24.
Improper Backflow Prevention on Kitchen and Exterior Water Connections
Penalty
Summary
The facility failed to ensure that appropriate backflow prevention was installed on cross connections. During the kitchen tour, an overhead spray nozzle was observed sitting below the flood rim in the garbage disposal. At the time of the observation, the Certified Dietary Manager stated she had just been using it and forgot to put it back on the hook. The Regional Maintenance staff later stated they were in the process of replacing the sink and the overhead spray nozzle in the kitchen and showed the order for the parts. Additional observations found a hose with a spray nozzle attached downstream of a hose bib atmospheric vacuum breaker on the outside spigot near the front of the building, and the Regional Maintenance staff removed the spray nozzle. A similar condition was observed on a hose with an attached spray nozzle downstream of a hose bib atmospheric vacuum breaker on the outside spigot near the dining room/patio area, and the Maintenance Director and Regional Maintenance staff stated that normally the hoses do not have the spray nozzle attached. The report also cited the 2022 Food Code requirement for an air gap and the 2008 Cross Connection Manual guidance that atmospheric vacuum breakers shall not be installed where they will be under continuous pressure for more than 12 hours.
Failure to Assess and Plan for Resident with Sexual Deviant History
Penalty
Summary
The facility failed to ensure a comprehensive assessment and timely implementation of a care plan for a resident with a history of inappropriate sexual behaviors. Upon admission, the resident was not properly assessed, and staff were not informed of the resident's history or the presence of a law enforcement-ordered tether monitoring device. This lack of communication and assessment resulted in staff being unaware of the resident's background, which included a history of criminal sexual conduct and incarceration. The resident, who was admitted with multiple diagnoses including Parkinson's disease, dementia, and anxiety, was observed with a tether on their ankle. Despite the presence of this device, the facility did not include specific information about the tether in the care plan. The resident's care plan was only updated to address sexually inappropriate behaviors after the resident made inappropriate comments to staff. Interviews with staff revealed that they were not informed of the resident's criminal history or the conditions of the tether, leading to concerns about the safety of staff and visitors, especially children who visit the facility. The facility's admission process, which includes background checks, failed to adequately inform staff of the resident's history and current needs. The Director of Nursing and Administrator admitted to not knowing the conditions of the resident's tether or the full extent of the resident's behavioral history. This lack of knowledge and comprehensive assessment hindered the facility's ability to create a meaningful care plan and ensure the safety of all individuals within the facility. The facility's policies on behavior management and baseline care planning did not address the need for comprehensive assessment and care planning, contributing to the deficiency.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADL) care, including showers, nail care, hair care, and general hygiene, for six residents. This deficiency was identified through observations, interviews, and record reviews. The facility's policy on ADL care emphasizes minimizing the loss of residents' functional abilities and maintaining good grooming and hygiene. However, the facility did not adhere to this policy, resulting in unmet hygiene needs and resident dissatisfaction. Resident #29, who has memory loss and is legally blind, reported infrequent showers and was observed with unkempt hair. The resident's care records indicated inconsistent bathing schedules, with several days marked as 'Response not required.' Similarly, Resident #178, admitted for respite care, did not receive regular showers as per their care plan, leading to complaints about irregular shower times. The care plan lacked specific days for bathing, contributing to the inconsistency. Other residents, including Resident #27, #6, #25, and #31, also experienced inadequate ADL care. Observations noted issues such as matted hair, unshaven faces, and long, unclipped nails. These residents required assistance with all ADLs due to conditions like dementia, cognitive impairment, and physical disabilities. Despite care plans indicating the need for regular bathing and personal hygiene assistance, the facility failed to provide the necessary care, resulting in visible signs of neglect and complaints from residents and family members.
Deficiency in Meal Palatability and Presentation
Penalty
Summary
The facility failed to provide palatable meals for four residents, resulting in complaints about the quality of the food served. On September 3, 2024, Resident #36 reported that the sweet potato served was too dry to eat, requiring them to cut off the top and consume only the inside. Similarly, Resident #57 found their yam to be dried and crusted, and their bread was soggy from ham juice. The Certified Dietary Manager (CDM) explained that the yams were simply cut in half and baked without any butter or oil to keep them moist, and bread was placed directly on the plate. Resident #9 and Resident #7 also complained about the dryness of the yams and potatoes served at lunch. On September 4, 2024, Resident #36 again experienced soggy bread due to it being placed on baked beans, further indicating issues with meal preparation and presentation.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by several observations during a kitchen walkthrough. Expired food items, such as sliced ham and lettuce, were found in the refrigerator, indicating a failure to adhere to the U.S. Public Health Service 2009 Food Code requirements for disposing of potentially hazardous foods past their use-by dates. Additionally, clean kitchenware, including small plastic bowls, a coffee cup, and white plates, were found with dried food particles, suggesting inadequate cleaning practices. During an interview, the Registered Dietitian mentioned a shortage of staff, which may have contributed to these lapses in maintaining kitchen hygiene. Further observations during a dining task revealed improper food handling practices by a dietary staff member. The staff member was seen with gloved hands resting on their hips and then proceeded to serve food without performing hand hygiene, using the same gloves to handle buttered bread and place it directly on plates. This action was noted by the Infection Control Nurse, who was informed of the incident and planned to provide education to address the issue. These deficiencies in food handling and kitchen sanitation practices pose a risk of foodborne illness to the 71 residents consuming food from the facility's kitchen.
Failure to Maintain Sanitary Conditions in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the A-Hall, which is a secured unit for memory care, dementia, and behavioral residents. Observations revealed a strong odor of urine emanating from the carpet in the hallway leading to the main dining/activity room. Interviews with staff members, including a housekeeper, CNA, and the Director of Nursing, indicated that the carpet was stained with bodily waste from the first day it was installed and that it was a poor choice for the unit due to frequent soiling by residents. Staff expressed frustration over the time-consuming nature of cleaning the carpet daily, which detracted from their other duties. The Director of Housekeeping acknowledged the decision to install carpet in the A-Hall as a mistake, noting the need to use a carpet machine every morning to manage the odors. The facility's Safe and Homelike Policy, dated July 28, 2020, stated that the facility would minimize and report lingering odors and maintain a sanitary and comfortable environment. However, the persistent foul odors and unsanitary conditions in the A-Hall indicate a failure to adhere to this policy, resulting in an environment that is neither safe nor homelike for residents and staff.
Failure to Include PTSD Diagnosis in Admission Assessment
Penalty
Summary
The facility failed to include a Post Traumatic Stress Disorder (PTSD) diagnosis in the comprehensive admission assessment for a resident, as noted on the CMS 802 form. This oversight was identified during an annual recertification survey. The resident, who was admitted for respite care, had a documented medical history of PTSD, along with Chronic Obstructive Pulmonary Disease (COPD) and dementia. Despite this, the PTSD diagnosis was not initially recorded on the CMS 802 form, which is used for comprehensive assessments. The deficiency was discovered through a combination of observation, interviews, and record reviews. The resident was observed in a semi-private room and was able to communicate with the surveyor about his care. During an interview, the MDS assessment nurse explained the process for completing assessments, noting that the 5-day assessment for the resident was due on the day of the interview. It was only after this interview that the revised CMS 802 form was provided, correctly identifying the resident's PTSD diagnosis.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident requiring oxygen therapy at bedtime and assistance with activities of daily living (ADLs), specifically showers. The resident, admitted for respite care with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), dementia, and Post Traumatic Stress Disorder (PTSD), reported not receiving a shower for over a week, and the care plan lacked specific days for bathing. The resident's electronic medical record indicated a need for home oxygen at 3 liters for nighttime use, but the care plan did not include interventions for oxygen therapy or monitoring of nighttime oxygen saturation levels. Observations and record reviews revealed discrepancies in the administration of oxygen therapy. The resident's physician order specified oxygen via nasal cannula at 2 liters at bedtime, but the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed administration at 8:00 AM. Additionally, the care plan did not address the resident's need for oxygen therapy, and there were no interventions for monitoring oxygen saturation levels at night. These oversights resulted in the likelihood of unmet needs for the resident.
Failure to Administer Nighttime Oxygen Therapy
Penalty
Summary
The facility failed to ensure the administration of oxygen at bedtime for a resident with Chronic Obstructive Pulmonary Disease (COPD) who required home oxygen at 3 liters for nighttime use. Upon admission, the resident's referral packet indicated the need for home oxygen, but the facility did not provide oxygen until four days after admission. During this period, the resident was without the necessary oxygen therapy, which could lead to oxygen desaturation, confusion, and shortness of breath/hypoxia at night. The facility's 'Oxygen Administration' policy requires oxygen to be administered under a physician's order and documented in the resident's care plan. However, the resident's care plan lacked any interventions for monitoring nighttime oxygen saturation levels. Interviews with staff revealed that the referral process was being updated, and the resident's home oxygen requirement was overlooked. The Director of Nursing acknowledged that the resident's need for home oxygen was missed during the admission process, resulting in the resident being without oxygen therapy for four days.
Unsanitary Conditions of Medication and Treatment Carts
Penalty
Summary
The facility failed to maintain cleanliness and sanitation of medication and treatment carts, as observed during a survey. Three out of five medication carts and one out of two treatment carts were found to be in unsanitary conditions. Specifically, medication carts C and D had crushed medications and papers in the drawers, while cart A had loose pills and white sprinkles of medication in the drawers. Additionally, the treatment cart for C and D hall had a large container of ketoconazole shampoo with excessive dried shampoo drippings on its sides and top. These observations were made in the presence of two LPNs, who indicated that the night shift was responsible for cleaning the medication carts. The facility's Medication Storage policy, dated October 30, 2020, mandates that all medications be stored according to the manufacturer's recommendations, ensuring proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. However, the observed conditions of the medication and treatment carts indicate a failure to adhere to this policy, resulting in unsanitary conditions and potential cross-contamination. The report also notes the unaccounted loss of one medication, further highlighting the deficiencies in medication management and storage practices at the facility.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences and dislikes of two residents, leading to decreased food intake and frustration. On one occasion, a resident was found with a lunch meal that did not include the tomato soup and grilled cheese listed on their meal ticket, and they were only able to eat the ham provided, which lacked mustard. Another resident received a meal that did not include the cottage cheese indicated on their meal ticket. The Certified Dietary Manager (CDM) acknowledged that the grilled cheese and tomato soup should have been provided and explained that the facility ran out of cottage cheese due to a supply issue with Sysco. Further observations revealed that one resident's breakfast meal, which included scrambled eggs, was left untouched because the resident disliked eggs, as noted on their meal ticket. The CDM confirmed that the residents should have received the items listed on their meal tickets, including any additional items circled. The failure to provide the correct meal items as per the residents' preferences and dislikes resulted in dissatisfaction and potential hunger for the residents involved.
Failure to Ensure Resident Dignity and Address Grievances
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple complaints against a Certified Nursing Assistant (CNA G) for unprofessional behavior. Residents reported that CNA G was often rude, rushed, and disrespectful during care, which led to feelings of anxiety and frustration among the residents. Specific incidents included a resident being told to 'do it yourself' when requesting assistance, and another resident almost falling due to rushed care. These behaviors were reported by several residents and staff members, indicating a pattern of unprofessional conduct by CNA G. The facility also failed to adequately address and document grievances and concerns raised by residents. Quality Assistance Forms were incomplete, lacking follow-up documentation, signatures, and resolutions. Despite multiple reports and complaints from residents and staff, the facility did not take effective action to resolve the issues with CNA G's behavior. This lack of follow-up and resolution contributed to ongoing dissatisfaction and anxiety among the residents. Additionally, the Resident Council raised concerns about CNA G's behavior, which were not properly addressed by the facility's management. The facility's policy on Resident Council responsibilities and grievance procedures was not effectively implemented, as evidenced by the lack of documented resolutions and follow-up actions. This failure to address resident grievances and ensure respectful treatment resulted in a deficiency in the facility's care standards.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice for medication administration, affecting six residents. For Resident #17, a dose of Hydrocodone-Acetaminophen was administered after the medication had been discontinued, and there was no documentation of this administration in the electronic Medication Administration Record. Resident #18 did not have their blood pressure assessed before the administration of Lisinopril and Propranolol, which were given on multiple occasions without following the physician's parameters. Additionally, the controlled substance was not signed out properly, indicating a lapse in the facility's medication administration policy. Resident #19's medication administration record showed discrepancies similar to Resident #18, where the controlled substance was not signed out, yet documented as administered. Resident #23 received doses of Diltiazem and Metoprolol without prior assessment of blood pressure or pulse, contrary to the physician's orders. Resident #14 was administered Hydralazine despite blood pressure readings below the physician's specified parameters, and Clonidine was not administered when blood pressure readings exceeded the threshold for its use. Resident #21 also experienced issues with medication administration, where Hydralazine was not given despite blood pressure readings indicating it was needed. Interviews with the Staff Development Coordinator and the Director of Nursing confirmed these medication administration errors, highlighting a failure to follow the facility's policy and nursing standards. The facility's policy requires vital signs to be recorded and medications to be signed out, which was not consistently followed, leading to these deficiencies.
Failure to Appoint Legal Guardian for Incompetent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was deemed incompetent to make medical decisions, had a legal guardian in place to guide medical decision-making according to the resident's Advanced Directives. The resident, who had diagnoses including heart disease, kidney disease, type 2 diabetes, major depressive disorder, anxiety, and a history of transient ischemic attack and cerebral infarction, was admitted with a financial conservator but not a medical guardian. Despite being assessed as incapable of making medical decisions due to severe cognitive impairment and dementia, the facility did not arrange for a legal guardian to be appointed. The facility's policy required periodic assessment of residents' decision-making abilities and arranging for an appropriate representative if necessary. However, the facility did not have evidence of attempting to obtain legal guardianship for the resident, despite the resident's incapacity being documented since August 2022. Interviews with family members and staff confirmed the lack of communication and action regarding the resident's guardianship status, leading to a failure in honoring the resident's right to have medical decisions made by a designated representative.
Failure to Timely Assess and Monitor Resident Post-Fall
Penalty
Summary
The facility failed to ensure timely assessment and adequate monitoring of a resident who experienced a fall, resulting in a delay in care and treatment for an acute T11 spinal fracture. The resident, a cognitively intact elderly female with a history of spinal issues, fell on an unwitnessed occasion and complained of upper back pain. Despite this, the initial assessment did not include a comprehensive evaluation of her spine or a detailed pain assessment, and there was no documentation of ongoing neurological assessments. The nurse on duty at the time of the fall conducted a basic assessment and notified the on-call provider but did not receive any new orders. The nurse did not perform any further comprehensive assessments throughout her shift, only periodically checking on the resident visually. The following day, the resident's pain worsened, and she was eventually sent to the emergency room for evaluation, where an acute T11 compression fracture was diagnosed. The facility's documentation and communication were inadequate, as there was no comprehensive physical assessment following the fall, and the physician was not notified in a timely manner. The resident's pain was not managed effectively, leading to a significant delay in identifying and treating the acute spinal fracture. This deficiency highlights a failure to adhere to the facility's fall prevention program and proper pain assessment protocols.
What surveyors are citing around you — mapped
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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 30 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 Tawas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Manor Healthcare Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Iosco County Medical Care Facility | 0.5 mi | ★★★★★ | 30 | 0 |
| Medilodge Of Sterling | 27.8 mi | ★★★★★ | 6 | 0 |
| Jamieson Nursing Home | 27.9 mi | ★★★★★ | 12 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 29 mi | ★★★★★ | 13 | 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.