Medilodge of Tawas City

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 12, 2025

  Based on interview and record review, the facility failed to ensure that two residents (Resident #9 and Resident #72) were adequately supervised to prevent falls out of 5 residents reviewed for falls, resulting in the likelihood of a fear of falling, skin tears, head injuries with hospitalization and repeated individual falls. Resident #9: Record review of the facility provided CMS-802 'Resident Matrix' identified Resident #9 as had a fall with injury. An observation and interview on 09/10/2025 at 10:19 AM with Resident #9 revealed that she was laying on the top of her bed with the room partition/privacy curtain pulled so that the resident could not be observed from the doorway of the room. […]

• Actual harm, isolatedF686Jul 12, 2022

  Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure comprehensive pressure ulcer assessment, care and management per professional standards of practice including documentation, diligent infection control practices, implementation of personalized interventions and monitoring of interventions to prevent the development of pressure ulcers for one resident (Resident #21) of four residents reviewed. This deficient practice resulted in a lack of pressure ulcer identification, assessment, and documentation. […]

• Actual harm, isolatedF690Jul 12, 2022

  Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure that indwelling urinary catheter care was conducted according to professional standards of practice, for one resident (Resident #21) of four residents reviewed, resulting in Resident #21's catheter being maintained in an unsanitary matter, a lack of documentation of care and monitoring per the Health Care Provider's (HCP) order, repeated Urinary Tract Infections ([CONDITION(S)]), hospitalization for a [CONDITION(S)] with [CONDITION(S)] (infection throughout the body), and the likelihood for a decline in the resident's overall health status. Findings include: Resident #21: On 6/21/22 at 12:01 PM, Resident # 21 was observed in their room in bed. […]

• Actual harm, isolatedF686Jun 10, 2021

  Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure interventions were implemented and in place to prevent the development of a pressure ulcer (wound caused by pressure) for one resident (Resident #35) of four residents reviewed, resulting in the development of a Stage III pressure ulcer (full thickness tissue loss) with significant tunneling which necessitated surgical intervention, pain, and the likelihood for decline and medical complications. Findings include: Resident #35: On 6/8/21 at 10:07 AM, Resident #35 was observed in their room in bed, partially covered by a sheet with their bare legs and chest exposed. An alternating air mattress was present on the Resident's bed. […]

• Actual harm, isolatedF689Jun 10, 2021

  Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure adequate supervision and monitoring to prevent falls for two residents (Resident #41 and Resident #158) of three residents reviewed for falls, resulting in lack of staff supervision, lack of implementation of basic care and interventions including appropriately sized clothing, and Resident #41 experiencing a fall with segmental fracture to their ulna bone fracture (fracture composed of at least two fracture lines isolate a segment of bone frequently associated with a high energy mechanism injury, devascularization of the segmental fracture fragments, and are linked to increased morbidity and long-term complications including delayed bone union, non-union of the bone,… […]