Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Tawas City during CMS and state inspections, most recent first.
A facility failed to comprehensively assess and implement a care plan for a resident with a history of inappropriate sexual behaviors and a law enforcement-ordered tether. Staff were not informed of the resident's criminal history, leading to concerns about safety, especially with children visiting the facility. The lack of communication and assessment hindered the creation of a meaningful care plan.
The facility failed to provide timely assistance with ADL care, including showers and hygiene, for several residents, leading to unmet needs and complaints. Observations noted issues like unkempt hair and unshaven faces, despite care plans indicating the need for regular assistance. Residents with conditions such as dementia and cognitive impairment were affected, highlighting a lack of adherence to the facility's ADL policy.
The facility failed to provide palatable meals, leading to complaints from four residents about dry yams and soggy bread. A resident had to cut off the top of a dry sweet potato, while another found their yam dried and bread soggy from ham juice. The CDM stated that yams were baked without butter or oil, and bread was placed directly on the plate. Another resident experienced soggy bread from baked beans, highlighting issues with meal preparation.
The facility failed to maintain a sanitary kitchen and proper food handling practices, as observed during a walkthrough and dining task. Expired food items were found, and kitchenware had dried food particles. A dietary staff member served food without proper hand hygiene, using gloves that had touched their hips. These deficiencies risk foodborne illness for 71 residents.
The facility failed to maintain a clean and homelike environment in the memory care unit, where a strong urine odor was present due to a carpet that was frequently soiled by residents. Staff interviews revealed dissatisfaction with the carpet choice, as it required daily cleaning and detracted from other duties. The facility's policy to minimize odors was not upheld, leading to unsanitary conditions.
A facility failed to include a PTSD diagnosis in a resident's admission assessment, as noted on the CMS 802 form. The resident, admitted for respite care, had a documented history of PTSD, COPD, and dementia. This oversight was identified during an annual recertification survey, and the correct diagnosis was only recorded after the surveyor's observation and interview with the MDS assessment nurse.
A facility failed to create a comprehensive care plan for a resident with COPD, dementia, and PTSD, who required oxygen therapy at bedtime and assistance with ADLs. The resident reported not receiving regular showers, and the care plan lacked specific days for bathing. Additionally, the care plan did not include interventions for oxygen therapy or monitoring of nighttime oxygen saturation levels, leading to the likelihood of unmet needs.
A resident with COPD requiring nighttime oxygen therapy was admitted to the facility without receiving the necessary oxygen for four days. The facility's referral process failed to ensure the administration of oxygen as per the resident's needs, and the care plan lacked interventions for monitoring nighttime oxygen saturation levels. Staff interviews revealed that the oversight occurred during the admission process.
The facility failed to maintain cleanliness and sanitation of medication and treatment carts, with three medication carts and one treatment cart found in unsanitary conditions. Crushed medications, loose pills, and dried shampoo drippings were observed, indicating a failure to adhere to the facility's Medication Storage policy. The night shift was responsible for cleaning the carts, but deficiencies in medication management and storage practices were evident.
The facility failed to provide meals according to the preferences and dislikes of two residents, resulting in decreased food intake and frustration. One resident did not receive the tomato soup and grilled cheese listed on their meal ticket, while another did not receive the cottage cheese indicated. The CDM acknowledged the oversight and cited a supply issue for the missing cottage cheese. Additionally, a resident's breakfast meal was left untouched due to a dislike of eggs, which was noted on their meal ticket.
A CNA in an LTC facility was reported by multiple residents and staff for being rude, rushed, and disrespectful, leading to anxiety and frustration among residents. The facility failed to adequately document and address these grievances, resulting in a deficiency in care standards.
The facility failed to follow professional standards for medication administration, affecting six residents. Errors included administering medications outside physician-ordered parameters, not signing out controlled substances, and failing to assess vital signs before administering certain medications. These actions led to discrepancies in medication records and non-compliance with facility policies.
A facility failed to appoint a legal guardian for a resident deemed incompetent to make medical decisions, despite the resident's severe cognitive impairment and dementia. The resident had a financial conservator but no medical guardian, and the facility did not arrange for guardianship despite policy requirements. Interviews confirmed the lack of communication and action regarding the resident's guardianship status.
A resident with a history of spinal issues experienced an unwitnessed fall and complained of back pain. The facility failed to conduct a comprehensive assessment or timely notify a physician, resulting in a delay in diagnosing an acute T11 spinal fracture. The resident's pain worsened, and she was eventually sent to the ER, where the fracture was identified.
Failure to Assess and Plan for Resident with Sexual Deviant History
Penalty
Summary
The facility failed to ensure a comprehensive assessment and timely implementation of a care plan for a resident with a history of inappropriate sexual behaviors. Upon admission, the resident was not properly assessed, and staff were not informed of the resident's history or the presence of a law enforcement-ordered tether monitoring device. This lack of communication and assessment resulted in staff being unaware of the resident's background, which included a history of criminal sexual conduct and incarceration. The resident, who was admitted with multiple diagnoses including Parkinson's disease, dementia, and anxiety, was observed with a tether on their ankle. Despite the presence of this device, the facility did not include specific information about the tether in the care plan. The resident's care plan was only updated to address sexually inappropriate behaviors after the resident made inappropriate comments to staff. Interviews with staff revealed that they were not informed of the resident's criminal history or the conditions of the tether, leading to concerns about the safety of staff and visitors, especially children who visit the facility. The facility's admission process, which includes background checks, failed to adequately inform staff of the resident's history and current needs. The Director of Nursing and Administrator admitted to not knowing the conditions of the resident's tether or the full extent of the resident's behavioral history. This lack of knowledge and comprehensive assessment hindered the facility's ability to create a meaningful care plan and ensure the safety of all individuals within the facility. The facility's policies on behavior management and baseline care planning did not address the need for comprehensive assessment and care planning, contributing to the deficiency.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADL) care, including showers, nail care, hair care, and general hygiene, for six residents. This deficiency was identified through observations, interviews, and record reviews. The facility's policy on ADL care emphasizes minimizing the loss of residents' functional abilities and maintaining good grooming and hygiene. However, the facility did not adhere to this policy, resulting in unmet hygiene needs and resident dissatisfaction. Resident #29, who has memory loss and is legally blind, reported infrequent showers and was observed with unkempt hair. The resident's care records indicated inconsistent bathing schedules, with several days marked as 'Response not required.' Similarly, Resident #178, admitted for respite care, did not receive regular showers as per their care plan, leading to complaints about irregular shower times. The care plan lacked specific days for bathing, contributing to the inconsistency. Other residents, including Resident #27, #6, #25, and #31, also experienced inadequate ADL care. Observations noted issues such as matted hair, unshaven faces, and long, unclipped nails. These residents required assistance with all ADLs due to conditions like dementia, cognitive impairment, and physical disabilities. Despite care plans indicating the need for regular bathing and personal hygiene assistance, the facility failed to provide the necessary care, resulting in visible signs of neglect and complaints from residents and family members.
Deficiency in Meal Palatability and Presentation
Penalty
Summary
The facility failed to provide palatable meals for four residents, resulting in complaints about the quality of the food served. On September 3, 2024, Resident #36 reported that the sweet potato served was too dry to eat, requiring them to cut off the top and consume only the inside. Similarly, Resident #57 found their yam to be dried and crusted, and their bread was soggy from ham juice. The Certified Dietary Manager (CDM) explained that the yams were simply cut in half and baked without any butter or oil to keep them moist, and bread was placed directly on the plate. Resident #9 and Resident #7 also complained about the dryness of the yams and potatoes served at lunch. On September 4, 2024, Resident #36 again experienced soggy bread due to it being placed on baked beans, further indicating issues with meal preparation and presentation.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by several observations during a kitchen walkthrough. Expired food items, such as sliced ham and lettuce, were found in the refrigerator, indicating a failure to adhere to the U.S. Public Health Service 2009 Food Code requirements for disposing of potentially hazardous foods past their use-by dates. Additionally, clean kitchenware, including small plastic bowls, a coffee cup, and white plates, were found with dried food particles, suggesting inadequate cleaning practices. During an interview, the Registered Dietitian mentioned a shortage of staff, which may have contributed to these lapses in maintaining kitchen hygiene. Further observations during a dining task revealed improper food handling practices by a dietary staff member. The staff member was seen with gloved hands resting on their hips and then proceeded to serve food without performing hand hygiene, using the same gloves to handle buttered bread and place it directly on plates. This action was noted by the Infection Control Nurse, who was informed of the incident and planned to provide education to address the issue. These deficiencies in food handling and kitchen sanitation practices pose a risk of foodborne illness to the 71 residents consuming food from the facility's kitchen.
Failure to Maintain Sanitary Conditions in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the A-Hall, which is a secured unit for memory care, dementia, and behavioral residents. Observations revealed a strong odor of urine emanating from the carpet in the hallway leading to the main dining/activity room. Interviews with staff members, including a housekeeper, CNA, and the Director of Nursing, indicated that the carpet was stained with bodily waste from the first day it was installed and that it was a poor choice for the unit due to frequent soiling by residents. Staff expressed frustration over the time-consuming nature of cleaning the carpet daily, which detracted from their other duties. The Director of Housekeeping acknowledged the decision to install carpet in the A-Hall as a mistake, noting the need to use a carpet machine every morning to manage the odors. The facility's Safe and Homelike Policy, dated July 28, 2020, stated that the facility would minimize and report lingering odors and maintain a sanitary and comfortable environment. However, the persistent foul odors and unsanitary conditions in the A-Hall indicate a failure to adhere to this policy, resulting in an environment that is neither safe nor homelike for residents and staff.
Failure to Include PTSD Diagnosis in Admission Assessment
Penalty
Summary
The facility failed to include a Post Traumatic Stress Disorder (PTSD) diagnosis in the comprehensive admission assessment for a resident, as noted on the CMS 802 form. This oversight was identified during an annual recertification survey. The resident, who was admitted for respite care, had a documented medical history of PTSD, along with Chronic Obstructive Pulmonary Disease (COPD) and dementia. Despite this, the PTSD diagnosis was not initially recorded on the CMS 802 form, which is used for comprehensive assessments. The deficiency was discovered through a combination of observation, interviews, and record reviews. The resident was observed in a semi-private room and was able to communicate with the surveyor about his care. During an interview, the MDS assessment nurse explained the process for completing assessments, noting that the 5-day assessment for the resident was due on the day of the interview. It was only after this interview that the revised CMS 802 form was provided, correctly identifying the resident's PTSD diagnosis.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident requiring oxygen therapy at bedtime and assistance with activities of daily living (ADLs), specifically showers. The resident, admitted for respite care with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), dementia, and Post Traumatic Stress Disorder (PTSD), reported not receiving a shower for over a week, and the care plan lacked specific days for bathing. The resident's electronic medical record indicated a need for home oxygen at 3 liters for nighttime use, but the care plan did not include interventions for oxygen therapy or monitoring of nighttime oxygen saturation levels. Observations and record reviews revealed discrepancies in the administration of oxygen therapy. The resident's physician order specified oxygen via nasal cannula at 2 liters at bedtime, but the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed administration at 8:00 AM. Additionally, the care plan did not address the resident's need for oxygen therapy, and there were no interventions for monitoring oxygen saturation levels at night. These oversights resulted in the likelihood of unmet needs for the resident.
Failure to Administer Nighttime Oxygen Therapy
Penalty
Summary
The facility failed to ensure the administration of oxygen at bedtime for a resident with Chronic Obstructive Pulmonary Disease (COPD) who required home oxygen at 3 liters for nighttime use. Upon admission, the resident's referral packet indicated the need for home oxygen, but the facility did not provide oxygen until four days after admission. During this period, the resident was without the necessary oxygen therapy, which could lead to oxygen desaturation, confusion, and shortness of breath/hypoxia at night. The facility's 'Oxygen Administration' policy requires oxygen to be administered under a physician's order and documented in the resident's care plan. However, the resident's care plan lacked any interventions for monitoring nighttime oxygen saturation levels. Interviews with staff revealed that the referral process was being updated, and the resident's home oxygen requirement was overlooked. The Director of Nursing acknowledged that the resident's need for home oxygen was missed during the admission process, resulting in the resident being without oxygen therapy for four days.
Unsanitary Conditions of Medication and Treatment Carts
Penalty
Summary
The facility failed to maintain cleanliness and sanitation of medication and treatment carts, as observed during a survey. Three out of five medication carts and one out of two treatment carts were found to be in unsanitary conditions. Specifically, medication carts C and D had crushed medications and papers in the drawers, while cart A had loose pills and white sprinkles of medication in the drawers. Additionally, the treatment cart for C and D hall had a large container of ketoconazole shampoo with excessive dried shampoo drippings on its sides and top. These observations were made in the presence of two LPNs, who indicated that the night shift was responsible for cleaning the medication carts. The facility's Medication Storage policy, dated October 30, 2020, mandates that all medications be stored according to the manufacturer's recommendations, ensuring proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. However, the observed conditions of the medication and treatment carts indicate a failure to adhere to this policy, resulting in unsanitary conditions and potential cross-contamination. The report also notes the unaccounted loss of one medication, further highlighting the deficiencies in medication management and storage practices at the facility.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences and dislikes of two residents, leading to decreased food intake and frustration. On one occasion, a resident was found with a lunch meal that did not include the tomato soup and grilled cheese listed on their meal ticket, and they were only able to eat the ham provided, which lacked mustard. Another resident received a meal that did not include the cottage cheese indicated on their meal ticket. The Certified Dietary Manager (CDM) acknowledged that the grilled cheese and tomato soup should have been provided and explained that the facility ran out of cottage cheese due to a supply issue with Sysco. Further observations revealed that one resident's breakfast meal, which included scrambled eggs, was left untouched because the resident disliked eggs, as noted on their meal ticket. The CDM confirmed that the residents should have received the items listed on their meal tickets, including any additional items circled. The failure to provide the correct meal items as per the residents' preferences and dislikes resulted in dissatisfaction and potential hunger for the residents involved.
Failure to Ensure Resident Dignity and Address Grievances
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple complaints against a Certified Nursing Assistant (CNA G) for unprofessional behavior. Residents reported that CNA G was often rude, rushed, and disrespectful during care, which led to feelings of anxiety and frustration among the residents. Specific incidents included a resident being told to 'do it yourself' when requesting assistance, and another resident almost falling due to rushed care. These behaviors were reported by several residents and staff members, indicating a pattern of unprofessional conduct by CNA G. The facility also failed to adequately address and document grievances and concerns raised by residents. Quality Assistance Forms were incomplete, lacking follow-up documentation, signatures, and resolutions. Despite multiple reports and complaints from residents and staff, the facility did not take effective action to resolve the issues with CNA G's behavior. This lack of follow-up and resolution contributed to ongoing dissatisfaction and anxiety among the residents. Additionally, the Resident Council raised concerns about CNA G's behavior, which were not properly addressed by the facility's management. The facility's policy on Resident Council responsibilities and grievance procedures was not effectively implemented, as evidenced by the lack of documented resolutions and follow-up actions. This failure to address resident grievances and ensure respectful treatment resulted in a deficiency in the facility's care standards.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice for medication administration, affecting six residents. For Resident #17, a dose of Hydrocodone-Acetaminophen was administered after the medication had been discontinued, and there was no documentation of this administration in the electronic Medication Administration Record. Resident #18 did not have their blood pressure assessed before the administration of Lisinopril and Propranolol, which were given on multiple occasions without following the physician's parameters. Additionally, the controlled substance was not signed out properly, indicating a lapse in the facility's medication administration policy. Resident #19's medication administration record showed discrepancies similar to Resident #18, where the controlled substance was not signed out, yet documented as administered. Resident #23 received doses of Diltiazem and Metoprolol without prior assessment of blood pressure or pulse, contrary to the physician's orders. Resident #14 was administered Hydralazine despite blood pressure readings below the physician's specified parameters, and Clonidine was not administered when blood pressure readings exceeded the threshold for its use. Resident #21 also experienced issues with medication administration, where Hydralazine was not given despite blood pressure readings indicating it was needed. Interviews with the Staff Development Coordinator and the Director of Nursing confirmed these medication administration errors, highlighting a failure to follow the facility's policy and nursing standards. The facility's policy requires vital signs to be recorded and medications to be signed out, which was not consistently followed, leading to these deficiencies.
Failure to Appoint Legal Guardian for Incompetent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was deemed incompetent to make medical decisions, had a legal guardian in place to guide medical decision-making according to the resident's Advanced Directives. The resident, who had diagnoses including heart disease, kidney disease, type 2 diabetes, major depressive disorder, anxiety, and a history of transient ischemic attack and cerebral infarction, was admitted with a financial conservator but not a medical guardian. Despite being assessed as incapable of making medical decisions due to severe cognitive impairment and dementia, the facility did not arrange for a legal guardian to be appointed. The facility's policy required periodic assessment of residents' decision-making abilities and arranging for an appropriate representative if necessary. However, the facility did not have evidence of attempting to obtain legal guardianship for the resident, despite the resident's incapacity being documented since August 2022. Interviews with family members and staff confirmed the lack of communication and action regarding the resident's guardianship status, leading to a failure in honoring the resident's right to have medical decisions made by a designated representative.
Failure to Timely Assess and Monitor Resident Post-Fall
Penalty
Summary
The facility failed to ensure timely assessment and adequate monitoring of a resident who experienced a fall, resulting in a delay in care and treatment for an acute T11 spinal fracture. The resident, a cognitively intact elderly female with a history of spinal issues, fell on an unwitnessed occasion and complained of upper back pain. Despite this, the initial assessment did not include a comprehensive evaluation of her spine or a detailed pain assessment, and there was no documentation of ongoing neurological assessments. The nurse on duty at the time of the fall conducted a basic assessment and notified the on-call provider but did not receive any new orders. The nurse did not perform any further comprehensive assessments throughout her shift, only periodically checking on the resident visually. The following day, the resident's pain worsened, and she was eventually sent to the emergency room for evaluation, where an acute T11 compression fracture was diagnosed. The facility's documentation and communication were inadequate, as there was no comprehensive physical assessment following the fall, and the physician was not notified in a timely manner. The resident's pain was not managed effectively, leading to a significant delay in identifying and treating the acute spinal fracture. This deficiency highlights a failure to adhere to the facility's fall prevention program and proper pain assessment protocols.
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What surveyors actually found near you
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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 Tawas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Manor Healthcare Center | 0.2 mi | — | 0 | 0 |
| Iosco County Medical Care Facility | 0.5 mi | — | 30 | 0 |
| Medilodge Of Sterling | 27.8 mi | — | 0 | 0 |
| Jamieson Nursing Home | 27.9 mi | — | 12 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 29 mi | — | 13 | 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.