Medilodge of Gaylord

In the surveyor’s words

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

• Actual harm, isolatedF685Feb 24, 2026

  This citation pertains to Intake 2727226.Based on observation, interview, and record review, the facility failed to act upon a physician's order for one Resident (#2) out of three residents reviewed for quality of care. This deficient practice caused delayed medical treatment for Resident #2 resulting in the need for transfer to an emergency department (ED) due to septic shock (a life-threatening condition which occurs when blood pressure drops to a dangerously low level after an infection).Findings include:Resident #2 (R2)Review of a complaint sent to the State Agency (SA) on 1/29/26, read, in part: .Since June/July of 2025, [R2] has been experiencing an issue with her eye. Staff at the facility were unable to coordinate [R2's] care and this has caused a delay in her service provision. […]

• Actual harm, isolatedF600Aug 6, 2025

  This citation pertains to intake 1234972Based on interview and record review, the facility failed to protect two Residents (#1 and #2) of four resident reviewed for right to be free from sexual abuse. This deficient practice resulted in psychosocial harm including feelings of embarrassment, devastation, anxiety, feelings of being violated, and trauma based on a reasonable person standard.Findings include:Review of a facility five-day investigation summary, submitted to the State Agency (SA) on 7/8/25 at 6:45 p.m., revealed the following: The Director of Nursing (DON) was notified by the Certified Nurses Assistant (CNA) that R1 was found in R2's bed.R2 was wearing her t-shirt and had her brief off.R1 was disrobed from the waist down and kneeling in another resident's bed.Resident #1… […]

• Actual harm, isolatedF684Jan 19, 2021

  Based on interview and record review, the facility failed to failed to appropriately monitor and recognize the signs of over-sedation for one Resident (#11) out of six residents reviewed for quality of care. This deficient practice resulted in harm when Resident #11 continued to receive medication with sedating effects, required the emergency administration of medication to reverse the sedation, and sustained a fall resulting in a head injury. Findings include: This citation pertains to Intake # 9. Resident #11 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #11's minimum data set (MDS) assessment, dated 12/3/20, revealed Resident #11 required limited, one-person physical assistance with transfers and walking. […]

• No harm, potential for more than minimal, widespreadF812Mar 19, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for all 70 residents living in the facility. Findings include: During a tour of the dietary department with Registered Dietitian (RD) A and Dietary Manager (DM) Q on 3/17/2026 at 12:18 PM, the following items were noted in the reach in freezer:an opened unsealed plastic bag in a manufacturer's box with beef patties exposed to air, and undated as to opened date and use by (expiration) datea partial bag of frozen formed cookie dough unlabeled and undated as to opened date and use by datea partial bag of frozen premade biscuits unlabeled and undated as to opened date and use by date.a partial bag of frozen hashbrowns… […]

• No harm, potential for more than minimal, widespreadF880Mar 19, 2026

  Based on observation, interview and record review, the facility failed to ensure correct implementation of transmission-based precautions (TBP) for one Resident (#87) of one resident reviewed for TBP and to ensure infection prevention and control policies were reviewed on an annual basis with the potential to affect all 70 residents living in the facility.Findings include:Resident #87 (R87) Review of the electronic medical record (EMR) revealed R87 was admitted to the facility on [DATE] and had diagnoses including sepsis due to methicillin susceptible staphylococcus aureus (MSSA) and osteomyelitis of the left ankle and foot. On 3/17/2026 at 1:42 p.m. R87 was observed self-propelling in a wheelchair toward his room from the entry of D-Hall, near the nurses' station. […]