Medilodge Of Gaylord
Medilodge of Gaylord in Gaylord, MI — inspection on February 24, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reviewed for quality of care.Findings include:Resident #1 (R1)Review of R1's Electronic Medical
neoplasm of the lung (cancer), fracture of T7-78 vertebra, post-laminectomy syndrome (chronic back, neck, or limb pain which remains after spinal surgery), chronic obstructive pulmonary disease (COPD), and retention of urine.On 2/23/26 at 2:49 PM, a telephone interview was conducted with Complainant A regarding R1's care at the facility.
Complainant A stated toward the end of R2's life, he was unable to swallow.
Complainant A recalled one nurse tried to administer a medication tablet with water which caused R1 to choke.
After that point, Complainant A stated the nurse staff would dissolve R1's pills in other medication liquids to form a solution.Review of R1's EMR revealed the following physician's orders: Lorazepam Oral Tablet 1 MG (milligram).
Give 1 tablet by mouth every 1 hour as needed for anxiety. initiated 10/14/25.
Atropine Sulfate Ophthalmic Solution.
Give 1 drop sublingually [under the tongue] every 1 hours as needed for end of life, 1-2 drops as needed for secretions. initiated 10/15/25.Further review of R1's EMR revealed the following entries by Registered Nurse (RN) G:Orders - Administration Note on 10/15/25 at 16:38 [4:38 PM]: .Patient not drinking, on hospice.Orders - Administration Note on 10/15/25 at 16:38 [4:38 PM]: .Patient not eating, on hospice.10/16/25 at 11:42 AM: .[patient] can no longer swallow.Review of R1's Medication Administration Record (MAR) revealed he was administered Lorazepam tablets 25 times after the initial note indicating he was no longer eating or drinking.On 2/24/26 at 9:45 AM, an interview was conducted with RN G regarding R1's end-of-life care.
When asked how R1was able to swallow Lorazepam tablets if he could no longer drink, eat, or swallow, RN G stated she dissolved the tablets in the Atropine to make a solution.
When asked if a physician's order was needed to change the form of the medication, RN G indicated, No, we've [the facility] always done it that way for residents who are end-of-life care.On 2/24/26 at 10:21 AM, a telephone interview was conducted with facility Pharmacy Consultant/Pharmacist H regarding R1's medication orders.
Pharmacist H indicated it is not standard of practice to dissolve a tablet into the solution of another medication.
Pharmacist H stated there is a liquid form of Lorazepam available, and the order could have been optimized by writing it in the liquid formalization.On 2/24/26 at 12:58 PM, an interview was conducted with the Director of Nursing (DON) regarding the expectations with the administration of medications in the prescribed form.
The DON stated according to the facility's standing orders, a medication can be crushed and dissolved into another medication unless contraindicated.
This Surveyor asked for the facility's standing order policy.On 2/24/26 at 1:36 PM, the DON and Nursing Home Administration (NHA) stated the facility did not have a standing orders policy.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
235350 02/24/2026
Medilodge of Gaylord 508 Random Lake Gaylord, MI 49735
referral. RN C stated after a referral is received from a provider, whether verbal, written, or in a
appointment.
When asked the reason for two separate ophthalmology referrals for R2, RN C could not
but somehow, it [the 6/26/25 referral] was missed and an ophthalmology appointment was not attempted to be scheduled until September.On 2/24/26 at 10:03 AM, R2 was observed lying in bed.
Her left eye appeared swollen, and approximately one third of her eye could be visualized due to the inflammation. R2 was unable to recall the events leading up to her hospitalization but stated the vision in her left eye was still, a little blurry.
235350 02/24/2026
Medilodge of Gaylord 508 Random Lake Gaylord, MI 49735
services of a licensed pharmacist.
ensure prescribed medications were readily available for one Resident (#1) of three residents
Record (EMR) revealed initial admission to the facility on 9/19/25 at 1:47 PM with diagnoses including malignant neoplasm of the lung (cancer), fracture of T7-78 vertebra, post-laminectomy syndrome (chronic back, neck, or limb pain which remains after spinal surgery), chronic obstructive pulmonary disease (COPD), and retention of urine.On 2/23/26 at 2:49 PM, a telephone interview was conducted with Complainant A regarding R1's care at the facility.
Complainant A stated R1 went a waited a significant amount of time for physician orders and missed the first dose of several medications as a result.Review of R1's EMR revealed the following physician's orders with a start date of 9/19/25: Morphine Sulfate ER [extended release] Tablet ER 30 MG [milligram].
Give 2 tablets by mouth every 12 hours for pain related to malignant neoplasm of.lung.
Flomax Capsule 0.4 MG.
Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia related to retention of urine.
Prochlorperazine Maleate Table 10 MG.
Give 1 tablet by mouth every 8 hours for Nausea; vomiting related to malignant neoplasm of.lung.Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT [micrograms per actuation]. 2 puff inhale orally every 12 hours for airway patency related to chronic obstructive pulmonary disease.Review of R1's Medication Administration Record (MAR) revealed the following missing doses of medications with the reason listed as, on order:Morphine Sulfate ER Tablet ER 30 MG: 9/19/25 evening dose.Flomax Capsule 0.4 MG: 9/19/25 dose.Prochlorperazine Maleate Table 10 MG: 9/19/25 evening dose and 9/20/25 morning dose.Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT: 9/19/25 evening dose.On 2/24/26 at 12:58 PM, an interview was conducted with the Director of Nursing (DON) regarding pharmacy orders for new admissions.
The DON stated that depending on the medication, it's not uncommon to have a delay in the prescription arriving at the facility resulting in a missed dose for a resident.
The DON explained that the facility kept a limited number of medications in their back-up supply and controlled substances can be delayed if there's an issue getting the physician's order to the pharmacy.
When asked if the facility reviews the resident's medications prior to their arrival, the DON stated, We don't always have their discharge orders until they get here.
Review of the facility policy titled, Orders - Admission, reviewed 1/30/24, read, in part: .A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide orders for the residents' immediate care and needs.The written orders should include at a minimum: .Medication orders if indicated.Review of the facility policy titled, Provider Pharmacy Requirements, revised 8/2020, read, in part: .The provider pharmacy agrees to perform all of, but not only, the following pharmaceutical services: .Providing routine and timely pharmacy service as contracted, as well as emergency pharmacy service 24 hours per day, seven days per week.