Medilodge of Cheboygan

In the surveyor’s words

From the most serious findings on record at Medilodge of Cheboygan, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 7, 2025

  This deficiency pertains to intake #2661622Based on interview and record review, the facility failed to protect the right of one Resident (R1) to be free from physical and verbal abuse by a staff member of three residents reviewed for abuse. This deficient practice resulted in psychosocial harm including feelings of humiliation and fear based on the reasonable-person concept. Findings include:A facility-reported incident (FRI) investigation summary submitted to the state agency on 11/3/25 disclosed Certified Nurse Aide (CNA) A and CNA B witnessed CNA C abuse Resident #1 (R1) while rendering post-fall assistance to R1 on 10/26/25. The facility investigation substantiated the abuse. […]

• Actual harm, isolatedF684Sep 26, 2024

  This citation pertains to intakes MI00147076 and MI00147197. Based on observation, interview and record review, the facility failed to ensure appropriate assessments and communication for change in condition for one Resident (#2) of three residents reviewed for change in condition, resulting in harm when Resident #2 was transferred to the hospital for mental status changes, found to have a severe wound infection and underwent subsequent intravenous antibiotic administration and surgical intervention. Findings include: Resident #2 (R2) Review of R2's Minimum Data Set (MDS) admission assessment, dated 6/24/2024, revealed the Resident was admitted to the facility on [DATE] and had diagnoses including lumbar fracture, diabetes, anxiety and dementia. […]

• Actual harm, isolatedF684Mar 11, 2024

  Intake #MI00143052 Based on interview and record review the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for one (resident #3) of one resident reviewed for diabetes management, resulting in diabetic ketoacidosis (emergent condition resulting from prolonged elevated blood sugar levels), hospitalization and death. Findings include: Resident #3 (R3) Review of the Electronic Medical Record (EMR) for R3, revealed the most recent admission to the facility was on 10/20/23 post fall at home with diagnoses including wedge compression fracture T5-T6, pelvis fracture, stage 4 sacral pressure ulcer, severe protein-calorie malnutrition, diabetes type II, peripheral vascular disease, colostomy, chronic kidney disease stage 3 and prior… […]

• Actual harm, isolatedF684Jun 14, 2022

  This citation pertains to Intake #MI 783. Based on interview and record review, the facility failed to identify, assess and treat a sutured wound, following admission, for one Resident (#1) of one reviewed for wounds. This deficient practice resulted in a re-hospitalization , infection, and prolonged healing. Findings include: According to the Admission Record, printed on 6/13/22, Resident #1 was admitted to the facility, from an acute care hospital, on 4/13/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged on [DATE], to an acute care hospital. The Nursing Admission Evaluation, dated 4/13/22 (part one), and 4/14/22 (parts two and three), revealed Resident #1 was able to follow commands and cooperate. […]

• Actual harm, isolatedF686Oct 21, 2021

  Based on observation, interview and record review, the facility failed to provide treatment and services to prevent the development of new stage II, facility acquired pressure ulcers for two Residents (#52 & #45) of three residents reviewed for pressure injuries. This deficient practice resulted in harm to Resident #52 with the development two new stage II facility acquired pressure ulcers, the potential for further skin breakdown and deterioration of condition. Findings include: Resident #52 Review of Resident #52's Minimum Data Set (MDS) assessment, dated 9/23/21, revealed Resident #52 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]