Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Alpena during CMS and state inspections, most recent first.
A resident with multiple fractures, obesity, and other conditions, receiving rehab services and care-planned for a two-person assist with bed mobility, was repositioned in bed by a single CNA during a bed check. The resident reported that the CNA roughly swung his legs into bed, shoved his shoulder against a mobility bar, and then flopped him back onto his back. Documentation by an LPN confirmed the CNA was alone during the care, and the resident later told Social Services that the CNA was not gentle and that he might contact law enforcement. A DPT reported the resident complained of being roughed up and having increased neck pain afterward, and facility leadership acknowledged that the care plan requiring two-person assistance was not followed.
The facility failed to provide diabetic foot care for a resident with diabetes, as her toenails were excessively long and podiatry services were not offered upon admission. Additionally, another resident did not receive proper assessments and documentation during the new admission process, with missing vital signs and weights, and a lack of communication regarding a change in physician. These deficiencies indicate lapses in the facility's care processes.
The facility failed to ensure proper medication administration and disposal for two residents. A resident's medications were left unattended without supervision, contrary to their care plan. Another resident's pills were found on the floor and improperly disposed of in the trash by an LPN, instead of using the designated disposal methods. The DON was aware of the incidents.
A resident with intact cognition and multiple diagnoses experienced a delay in receiving ordered x-rays after an incident where their toes were run over by another resident. The x-rays were ordered by a physician but not executed until days later, after the physician inquired about the results. Facility staff interviews revealed a lack of awareness and communication regarding the order, and the Director of Nursing could not explain the delay, despite existing policies for timely diagnostic test completion.
A resident with a history of heart failure and other conditions was admitted for rehab but experienced a change in condition that was not properly recognized by the facility. Despite lab results indicating potential sepsis, the sepsis pathway was not followed, and vital signs were not consistently monitored. The resident's condition worsened, leading to hospitalization and death from septic shock and infected wounds.
The facility failed to prevent pressure ulcers in two residents, leading to severe health issues. One resident developed multiple stage 3 ulcers due to delayed interventions and inadequate documentation of care refusals. Another resident acquired a stage 3 heel ulcer, with insufficient preventive measures in place. Staff interviews revealed compliance issues and pain during wound care, with no wound cultures conducted.
The facility failed to serve meals at a palatable temperature, affecting numerous residents who reported consistently cold food. Despite complaints raised in resident council meetings, no corrective actions were documented. Observations revealed delayed meal service, contributing to cold food, and inadequate equipment to maintain food temperature. The facility's policy on prompt meal service was not followed, leading to resident dissatisfaction.
A facility failed to maintain a medication administration error rate below five percent, resulting in an 8.00 percent error rate. A nurse administered an incorrect dosage of metoclopramide to a resident and failed to flush the G-tube with water before medication and tube feeding, contrary to the facility's policy. The errors were confirmed by the DON.
Failure to Follow Two-Person Assist Care Plan During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to provide safe bed mobility and adequate supervision by not following a resident’s care plan requiring a two-person assist. The resident had been admitted with multiple serious injuries, including wedge compression fractures of the thoracic vertebrae, multiple left rib fractures, a left clavicle fracture, depression, and obesity, and was receiving rehabilitation services. The resident’s care plan identified an ADL self-care performance deficit related to multiple conditions and specified that bed mobility required a two-person assist. On the evening in question, a CNA entered the resident’s room alone to perform a bed check and reposition the resident, despite the care plan requirement for two staff. The resident reported that the CNA threw his legs over the bed “like a sack of potatoes,” wrenched his shoulder, shoved his left shoulder against the assist/mobility bar, and then flopped him back onto his back after stating he was dry and clean. The resident’s account of being “manhandled” and having his shoulder hit the mobility bar was documented in an incident report completed by the unit manager LPN, which noted that the CNA was the only person present during the repositioning and bed check. The resident later expressed to Social Services that the CNA was not gentle enough and stated he would consider calling the police and obtaining a personal protection order if necessary. A Doctoral Physical Therapist reported that the resident complained of being “roughed up” during care by the CNA and that he was experiencing more neck pain after the incident. The unit manager LPN and the Nursing Home Administrator both confirmed that there had been an incident during care and that there should have been two CNAs performing the bed mobility, acknowledging that the resident was not transferred properly in bed and that the care plan requirement for a two-person assist was not followed.
Deficiencies in Diabetic Foot Care and New Admission Assessments
Penalty
Summary
The facility failed to provide adequate diabetic foot care for a resident with diabetes mellitus. The resident was observed with excessively long toenails, and despite having a care plan that included diabetic foot checks, there was no documentation of podiatry services being offered upon admission. The Director of Nursing (DON) and a Nurse Manager acknowledged the oversight, noting that podiatry services had recently visited the facility, but the resident was not included in the list to be seen. The facility's policy required foot care in accordance with professional standards, but this was not adhered to in the resident's case. Another deficiency involved the improper assessment and documentation for a newly admitted resident. The resident, who had multiple active diagnoses including diabetes mellitus and atrial fibrillation, did not have vital signs recorded for two consecutive days as required by the new admission process. Additionally, the resident's weight was not obtained on one of the ordered days, and skilled nursing assessments were completed using outdated vital signs. The DON confirmed these lapses and acknowledged that the resident's change of physician was not communicated to the new provider, which delayed appropriate medical intervention. These deficiencies highlight a failure in the facility's processes for ensuring quality care and proper documentation. The lack of diabetic foot care and the failure to perform and document necessary assessments for new admissions indicate a breach in the facility's policies and procedures, impacting the residents' health management and care outcomes.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and disposal practices for two residents. For one resident, medications were left unattended at the bedside without supervision, despite the resident's care plan indicating no desire for self-administration. The resident confirmed that the nurse did not observe the medication intake, which contradicts the facility's policy requiring observation of medication consumption. For another resident, pills were found on the floor and were improperly disposed of in the trash by an LPN, rather than using the designated drug buster or sharps container as per facility policy. The resident had a physician's order for a controlled medication, which requires specific disposal procedures. The DON acknowledged awareness of the incident and confirmed the improper disposal method used by the LPN.
Delay in Obtaining X-Ray Services for Resident
Penalty
Summary
The facility failed to ensure timely radiology exams for a resident, leading to a delay in obtaining necessary x-rays. The resident, who had intact cognition, was admitted with diagnoses including hypertension, depression, diabetes mellitus, and gout. An incident occurred where the resident's toes were run over by another resident in a wheelchair, causing pain. A physician ordered bilateral foot x-rays on January 20th, but the order was not executed promptly. The x-rays were eventually ordered on January 23rd, after the physician inquired about the results and discovered the oversight. Interviews with facility staff revealed a lack of awareness and communication regarding the x-ray order. A Licensed Practical Nurse did not recall receiving the order, and a Registered Nurse only became aware of the need for x-rays after the physician's inquiry. The Director of Nursing was unable to explain the delay, despite the facility's policy requiring timely completion and tracking of diagnostic tests. The x-rays, when finally conducted, showed no fractures, but the delay in obtaining them was a clear deficiency in the facility's processes.
Failure to Recognize Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to recognize a change in condition for a resident, leading to hospitalization and death. The resident, who had a history of congestive heart failure, chronic obstructive pulmonary disease, morbid obesity, and muscle weakness, was admitted for short-term rehabilitation. Despite lab results indicating elevated BNP levels and low white blood cell counts, there was no follow-up or new orders from the physician. The sepsis pathway was not properly followed, and vital signs were not consistently monitored or communicated to the physician. The resident's condition deteriorated with signs of sepsis, including hypotension, tachycardia, and mental status changes. However, the sepsis screening tool was incorrectly marked as negative, and the SBAR documentation was not accurately completed. The resident's refusal to eat and worsening wounds were noted, but there was no increased monitoring or intervention. Interviews with staff revealed a lack of adherence to the sepsis protocol and inadequate documentation of the resident's condition. The resident was eventually transported to the hospital, where he was diagnosed with septic shock and deep decubitus ulcers. Despite aggressive treatment, the resident's condition continued to decline, and he passed away shortly after admission. The facility's failure to promptly recognize and respond to the resident's change in condition, as well as the improper use of the sepsis pathway, contributed to the adverse outcome.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to prevent the development of pressure ulcers for two residents, leading to significant health complications. Resident #70 was admitted with no open skin areas, but later developed multiple pressure ulcers, including stage 3 ulcers, which were not present upon admission. The facility did not implement timely interventions for the resident's skin conditions, and there was a lack of consistent documentation and follow-up on the resident's refusal of care and turning and repositioning schedules. The resident's wounds worsened over time, resulting in sepsis and hospitalization, requiring wound debridement. Resident #70's care plan indicated a risk for impaired skin integrity due to morbid obesity, congestive heart failure, and muscle weakness. Despite this, interventions such as a low air loss mattress were delayed, and the resident's refusal to comply with certain care measures was not adequately addressed. The facility's staff failed to consistently document the resident's behaviors and refusals, which contributed to the deterioration of the resident's skin condition. Interviews with staff revealed that the resident experienced significant pain during wound care, and there was no evidence of wound cultures being taken to guide appropriate antibiotic treatment. Resident #33 also developed a facility-acquired pressure injury on the right heel, which progressed to a stage 3 ulcer. The resident's care plan initially included measures to float heels, but additional interventions were not implemented until after the injury developed. Staff interviews indicated that the resident was compliant with care, yet there was a lack of documentation regarding any refusals or interventions prior to the development of the deep tissue injury. The Director of Nursing confirmed that more interventions should have been in place before the injury occurred, highlighting a deficiency in the facility's pressure ulcer prevention practices.
Deficiency in Meal Temperature and Timeliness
Penalty
Summary
The facility failed to provide meals at a palatable temperature, affecting 19 out of 23 residents interviewed. Multiple residents reported that their food was consistently served cold, regardless of the meal. This issue was raised during resident council meetings, but no corrective actions were documented or implemented by the Certified Dietary Manager (CDM) or the Nursing Home Administrator (NHA). The facility's policy on resident council meetings indicated that concerns should be investigated, but the NHA claimed to be unaware of ongoing complaints about food temperature. Observations and interviews revealed that meal service was often delayed, contributing to the cold temperature of the food. Residents expressed frustration with the timeliness of meal delivery, with some waiting up to 45 minutes for their meals. The delay in meal service was observed during a lunch service, where many residents had not received their meals on time, leading to dissatisfaction and complaints about the food being cold. The facility lacked proper equipment to maintain food temperatures during delivery, as noted by a CNA who mentioned that the small open carts used for meal delivery did not keep food warm effectively. Despite the presence of staff in the dining room, meal service was not prompt, and residents continued to express dissatisfaction with the temperature and quality of their meals. The facility's policy on meal service emphasized prompt delivery and accommodation of preferences, which was not adhered to, as evidenced by the residents' complaints and observations made during the survey.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in an error rate of 8.00 percent. This was identified during an observation of medication administration by RN J for a resident, R10. RN J was observed dispensing 2.5 ml of metoclopramide oral solution, which was incorrect according to the physician's order that required 5 ml to be administered via G-tube. Upon verification, RN J acknowledged the mistake and administered an additional 2.5 ml. This error was part of three errors identified out of 25 opportunities. Additionally, RN J failed to flush R10's G-tube with water before administering medications and before tube feeding, as required by the facility's policy. The Director of Nursing confirmed the errors and stated that the expectation was for nurses to follow physician orders and policy for medication administration via G-tubes. The facility's policy and validation checklist for medication administration via feeding tubes were reviewed, which emphasized the importance of flushing the G-tube with water before and between medications.
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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 Alpena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Green View | 0.7 mi | — | 0 | 0 |
| Medilodge Of Hillman | 21.6 mi | — | 29 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 27.4 mi | — | 13 | 0 |
| Jamieson Nursing Home | 29.4 mi | — | 12 | 0 |
| Medilodge Of Rogers City | 30 mi | — | 0 | 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 August 2026) and official state health department websites.