Medilodge of Tawas City: Wound Care Failures Led to Sepsis - MI
That sequence of events is documented in a federal inspection report from Medilodge of Tawas City, following a complaint investigation completed August 12, 2025.
The resident had undergone cardiac surgery. By June 21, a nurse practitioner's notes described the surgical sites as well-approximated and showing no signs of infection. Then, on July 4, nursing staff documented eschar — dead tissue — on the sternal incision, with cracks forming in it. A shorter incision on the left lower leg, from a vein harvesting site, was also covered with eschar. Two days later, on July 6, a nursing note said the sternal incision was "more open" and would require close monitoring.
Nobody called the physician. Nobody called the nurse practitioner. No one measured the wounds or documented their odor, warmth, or any discharge. The wound nurse, according to her own interview with inspectors, never looked at the wounds at all.
On July 7, the resident was transferred to the hospital. She had sepsis.
Nurse B, reached by phone during the inspection, was asked directly whether she had contacted the physician or nurse practitioner on July 4 or July 6 about the eschar on the resident's sternum. "I don't remember calling them," she said. "I knew she had an upcoming appointment, I know she had labs done from the first time we sent her out for nose bleed. I did not call for the labs." She said she did not call anyone because she thought the appointment meant she could wait.
On July 4, when the resident was sent out for a nosebleed, hospital records contained no documentation that staff had flagged or examined the sternal or leg wound during that visit.
The nurse practitioner, identified in the report as NP E, was unambiguous about what should have happened. "They did not inform me of the eschar in the sternum surgical wound or the left leg," she told inspectors. "They should have."
The nurse manager, RN C, said she learned about none of it until after the transfer. "They were concerned about the nose bleeds, no one told me about the sternum wound or leg," she said. "They dropped the ball on that. I would have notified the provider."
The nurse educator, RN D, said the same. "No one informed me of the resident's condition. I would have thought the nurse would have informed somebody. I educate them on assessment and documentation."
Then there was the wound nurse.
The facility employs a licensed practical nurse specifically designated for wound care. That nurse told inspectors she does not take pictures, assess, monitor, or document anything related to surgical wounds. The reason: management told her not to. "I did not look at it," she said.
The facility's own wound treatment management policy, dated October 2023, states that the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders. The wound nurse said she was instructed to stay away from surgical wounds entirely.
The administrator, in an interview on August 12, did not dispute the findings. "The evidence does support we did not follow the care plan," the administrator said.
What the inspection report captures is a failure that compounded across multiple days and multiple staff members. A nurse saw dead tissue on a post-surgical chest wound and told no one. Two days passed. The wound got worse. The nursing notes acknowledged it was more open. Still no call to a provider. Still no wound measurements. Still no documentation of infection signs. The wound nurse, who might have intervened, had been directed away from exactly this kind of wound.
The resident arrived at the emergency room with sepsis — a systemic infection that can turn fatal within hours — three days after staff first noted the dying tissue on her chest.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, affecting few residents. The administrator confirmed the facility did not follow its own care plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Tawas City from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 4, 2026 · Our methodology
Medilodge of Tawas City in Tawas City, MI was cited for violations during a health inspection on August 12, 2025.
The resident had undergone cardiac surgery.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.