Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Cheboygan during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple health issues was physically and verbally abused by a CNA during post-fall care, including being kicked, slapped, and subjected to derogatory language. Witnessing staff reported concerns to a supervising RN, but immediate protective actions were not taken, and the CNA continued to have access to residents until the Nursing Home Administrator was fully informed and intervened. The facility's abuse prevention protocols were not followed, resulting in psychosocial harm to the resident.
The facility failed to implement effective infection prevention and control practices, including improper isolation of COVID-19 positive residents, inadequate use of PPE, and poor medication handling. Residents were not properly isolated, and staff did not follow protocols for PPE removal and equipment disinfection. Additionally, medication handling practices were compromised by the use of ungloved hands, leading to potential contamination.
The facility failed to provide a dignified dining experience for three residents. A resident on hospice was ignored by a social worker and fed facing away from others. Another resident received a cold meal left uncovered, and a third resident waited to be fed while watching others eat. Additionally, a resident was pulled backward in a chair down the hallway without staff intervention. The Nursing Home Administrator acknowledged these actions were inappropriate.
The facility failed to properly dispose of contaminated medications for three residents. An RN dispensed acetaminophen into her hand and discarded it in the garbage, another RN dropped a vitamin on the cart and disposed of it in a biohazard container, and an incorrect dosage of potassium was discarded in the garbage. The facility's policy requires using a drug destroyer for medication disposal, which was not followed.
Two residents experienced medication administration errors, including incorrect dosages and delayed administration due to unavailable medication. A nurse prepared the wrong dosage of potassium and administered an incorrect dosage of Ativan due to outdated instructions. Another resident's meloxicam was delayed, causing severe pain, and was falsely documented as administered on time. The facility's policies on medication administration and documentation were not followed.
Two residents experienced significant medication errors due to the facility's failure to administer medications as prescribed. One resident suffered severe pain due to a delay in receiving meloxicam, while another received incorrect dosages of Ativan for anxiety. The errors were compounded by inadequate communication with the pharmacy and lack of proper documentation and physician notification.
A resident with severe cognitive impairment and multiple diagnoses experienced harm due to the facility's failure to assess and communicate a change in condition. After sustaining a fall and skin tear, the resident's condition worsened without timely wound assessments or notifications to medical staff. This led to a hospital transfer where severe infection and necrotizing fasciitis were diagnosed, requiring surgical intervention.
A facility failed to provide written notification for a facility-initiated discharge to a resident's representative and the LTC Ombudsman. The resident, diagnosed with schizophrenia, was transferred to the ED and later admitted to a psychiatric facility. Despite an expected return, the facility did not provide a discharge notice or appeal information when deciding not to accept the resident back, considering them discharged due to an extended absence. The resident's legal guardian was only informed when asked to pick up the resident's belongings.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease and a history of stroke, was subjected to physical and verbal abuse by a Certified Nurse Aide (CNA) during post-fall assistance. The resident, who was non-ambulatory and required staff assistance for activities of daily living, was found on the floor after a fall. During the process of returning the resident to bed, CNA C was observed by two other CNAs to have kicked the resident multiple times, slapped the resident on the buttocks, and used derogatory language, calling the resident 'disgusting' in a loud and angry voice. The resident's disposable brief had fallen off, leaving him exposed during the incident, and he appeared startled, afraid, and in distress according to witness accounts. Despite witnessing the abuse, the initial response from staff was inadequate. CNA A reported discomfort with CNA C's actions to the supervising RN, but did not explicitly state that abuse had occurred, as she believed it was not her role to determine abuse but to report concerns. The RN did not immediately intervene, interview the involved staff, or remove CNA C from resident care duties. Instead, the RN delayed entering the resident's room and only reported the concern to the Nursing Home Administrator (NHA) after assessing the resident, without taking immediate protective measures or suspending the alleged abuser. The NHA was not made fully aware of the extent of the abuse until later in the day, after which CNA C was suspended and an investigation was initiated. Prior to this, CNA C continued to have access to residents. The facility's abuse prevention protocol, which requires prompt protection of residents and immediate reporting and investigation of abuse allegations, was not followed by the staff involved. The failure to act promptly and decisively resulted in psychosocial harm to the resident, including feelings of humiliation and fear, as substantiated by the facility's investigation.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to implement effective infection prevention and control practices for several residents, leading to potential transmission of communicable diseases. Residents with COVID-19 were not properly isolated, as room doors were left open despite signage indicating Transmission-Based Precautions (TBP). Additionally, there were no physician's orders or care plans for some residents placed in TBP. Staff members were observed exiting rooms of COVID-19 positive residents without removing personal protective equipment (PPE) and cleaning contaminated medical equipment in the hallway, contrary to infection control policies. In several instances, staff did not ensure that residents with COVID-19 wore masks or stayed in their rooms, increasing the risk of spreading the virus. For example, a resident was seen in the hallway without a mask, and staff did not redirect him back to his room or provide a mask. Another resident's face shield, which was potentially contaminated, was not properly disinfected after falling to the floor, and staff failed to address this breach in protocol. Medication handling practices also contributed to the deficiency. A nurse was observed using ungloved fingers to handle medications, contaminating them and the medication containers. The nurse also improperly handled blister packs by holding them against her uniform, which is against infection control standards. These actions were not in line with the facility's policy to prevent contamination during medication administration.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents, resulting in potential feelings of frustration, embarrassment, and humiliation. Resident #18, who was on hospice services and dependent on staff for eating, was observed in the dining room seated next to a hospice Social Worker who was preoccupied with a cell phone and laptop, not interacting with the resident or offering fluids. When the meal was finally served, the resident was turned away from the table and fed facing away from other residents. Resident #20 received a meal that had been left uncovered for approximately 11 minutes, resulting in cold food. Although a fresh meal was provided, the resident was not given a new roll or vegetables, and the original meal remained on the table. Resident #58, dependent on staff for all activities of daily living, was left waiting to be fed while watching other residents being assisted. When finally attended to, the meal was not reheated or checked for appropriate temperature. Additionally, Resident #18 was observed being pulled backward down the hallway in a high-back mobile reclining chair by a hospice CNA, with no intervention from other staff present. The Nursing Home Administrator acknowledged that the expectation was for all staff, including contracted personnel, to treat residents with dignity and respect, and that the observed actions were inappropriate. The facility's policy on promoting and maintaining resident dignity emphasizes treating each resident with respect and ensuring interactions are resident-focused, which was not adhered to in these instances.
Improper Disposal of Contaminated Medications
Penalty
Summary
The facility failed to appropriately dispose of contaminated medications for three residents during medication administration. For Resident #61, a Registered Nurse (RN) dispensed acetaminophen tablets directly into her hand and then discarded them into a garbage container after realizing the contamination. Similarly, for Resident #50, an RN dropped a vitamin on the medication cart and disposed of it in a biohazard container. In the case of Resident #47, an RN prepared an incorrect dosage of potassium, and upon realizing the error, disposed of the excess medication in the garbage container. The facility's nurse manager confirmed that the expected procedure for disposing of medications involved using a drug destroyer solution, which was available at the facility. However, the medications were not disposed of according to this protocol. The facility's policy on medication destruction specifies that drugs should be rendered unfit for human consumption by combining them with a drug destroyer or similar agent, which was not followed in these instances.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to ensure the correct dosages of prescribed medications were administered to two residents, resulting in a medication error rate of 9.38%. For one resident, a registered nurse (RN D) prepared and almost administered 20 milliequivalents (mEq) of potassium instead of the prescribed 10 mEq. This error was caught by a surveyor before administration. The mistake occurred because the blister pack of another resident was incorrectly placed in the medication cart section of the resident in question. Additionally, RN D administered an incorrect dosage of Ativan, giving only one tablet of 0.5 mg instead of the prescribed two tablets, due to outdated blister pack instructions. Another resident was prescribed meloxicam for pain, which was not administered as scheduled due to the medication not being available in the facility. The medication was ordered after the pharmacy's cut-off time, and the pharmacy was not contacted for a stat delivery. The resident experienced severe pain, rated ten out of ten, due to the delay. The medication was eventually administered using a supply brought in by the resident's family, but the administration was falsely documented as having occurred at the scheduled time. There was no documentation of the delay or notification to the physician about the unavailability of the medication. The facility's policy on medication errors requires that medications be administered according to the physician's orders, and any discrepancies should be documented and reported. However, in these cases, the nurses failed to adhere to these protocols, resulting in incorrect dosages and delayed administration without proper documentation or physician notification. The nurse managers confirmed that the expected procedure was not followed, highlighting a lapse in adherence to the facility's medication administration policies.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as prescribed for two residents, leading to significant medication errors. Resident #224 was prescribed meloxicam 15 mg daily for pain, but the medication was not administered as scheduled at 8:00 a.m. on 1/15/25. The medication was not available in the facility's emergency supply, and the pharmacy had not delivered it due to a late order. As a result, the resident experienced excruciating pain, rated ten out of ten. The medication was eventually administered at 2:37 p.m. using a supply brought in by the resident's family, but there was no documentation of the late administration or notification to the physician. Resident #47 was prescribed Ativan 1 mg three times daily for anxiety, but received an incorrect dosage due to a discrepancy between the physician's order and the medication available in the facility. The resident's blister pack contained lorazepam 0.5 mg tablets, and only one tablet was administered instead of the required two. This error occurred multiple times, and there was no documentation of the correct dosage being administered consistently. The facility's policy on medication errors emphasizes the importance of administering medications according to the physician's orders and documenting any significant errors. The facility's failure to adhere to medication administration protocols resulted in significant medication errors for both residents. The lack of timely communication with the pharmacy and the absence of proper documentation and physician notification contributed to these deficiencies. The facility's policy requires that any significant medication error be assessed, documented, and communicated to the prescriber, which was not followed in these cases.
Failure to Assess and Communicate Change in Condition
Penalty
Summary
The facility failed to ensure appropriate assessments and communication for a change in condition for a resident, resulting in harm. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and diabetes, was admitted to the facility and later transferred to a hospital due to mental status changes. The resident was found to have a severe wound infection that required intravenous antibiotics and surgical intervention. The resident sustained a fall resulting in a skin tear, which progressed into cellulitis. Despite the resident's increased confusion and behavior changes, there were no documented wound assessments or notifications to the wound care nurse or physician until several days later. The resident's condition worsened, leading to a hospital transfer where extensive cellulitis and necrotizing fasciitis were diagnosed, necessitating multiple surgical debridements. The facility's failure to conduct timely wound assessments and communicate changes in the resident's condition to the appropriate medical personnel contributed to the resident's deteriorating health. The facility's policy required notification of changes in condition, but this was not adhered to, resulting in delayed treatment and increased harm to the resident.
Failure to Provide Written Notification for Facility-Initiated Discharge
Penalty
Summary
The facility failed to provide written notification for a facility-initiated discharge to a resident's representative and the Office of the State Long-Term Care Ombudsman. This deficiency involved a resident with a primary diagnosis of schizophrenia who was transferred to the emergency department for psychological evaluation and subsequently admitted to a psychiatric facility. Despite the resident's legal guardian receiving a transfer notice indicating an expected return, the facility did not provide a written discharge notice or appeal information when they decided not to accept the resident back. The facility considered the resident discharged due to an extended absence without further communication with the hospital regarding the resident's status or the completion of a Level II PASSAR. The resident's legal guardian was not informed of the facility's decision until contacted to pick up the resident's belongings. The facility's policy required written notification of discharge and notification to the ombudsman, which was not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 1 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 Cheboygan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mackinac Straits Long Term Care Unit | 21.4 mi | — | 1 | 0 |
| Bay Bluffs-emmet County Medical Care Facility | 27.4 mi | — | 1 | 0 |
| The Villa At The Bay | 30.1 mi | — | 3 | 0 |
| Medilodge Of Rogers City | 34.6 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Medilodge Of Cheboygan.
100% money-back within 48 hours.
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.