Gaylord, MI

Medilodge of Gaylord

2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

508 Random Lake, Gaylord, MI

(989) 732-3508

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Medilodge

Operator or chain grouping

Approved since

1978-03-06

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

50 facilities

Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.18

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.53

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.47

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.17

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.71

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.71

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.91

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

1.10

CMS adjusted RN staffing hours

Adjusted total hours

3.91

CMS adjusted total nurse staffing hours

Case-mix index

1.46

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

39%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,720

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

19.37

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.52

Baseline 19.88% · Performance 19.80% · Measure score 3.52 · Achievement 3.52 · Improvement 0

Healthcare-associated infections

1.05

Baseline 8.90% · Performance 8.30% · Measure score 1.05 · Achievement 0 · Improvement 1.05

Total nurse turnover

2.63

Baseline 46.07% · Performance 52.94% · Measure score 2.63 · Achievement 2.63 · Improvement 0

Adjusted total nurse staffing

0.55

Baseline 3.34 hours · Performance 3.24 hours · Measure score 0.55 · Achievement 0.55 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.71%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 97 · Observed rate 8.25% · Lower 95% interval 7.22%
Discharge to community	60.58%	50.57% 10 pts better	No Different than the National Rate · Eligible stays 74 · Observed rate 51.35% · Lower 95% interval 47.55%
Medicare spending per beneficiary	0.98	1.02 About the same
Drug regimen review with follow-up	96.1%	95.27% 0.8 pts better	Numerator 74 · Denominator 77
Falls with major injury	1.3%	0.77% 0.5 pts worse	Numerator 1 · Denominator 77
Discharge self-care score	54.17%	53.69% 0.5 pts better	Numerator 26 · Denominator 48
Discharge mobility score	54.17%	50.94% 3.2 pts better	Numerator 26 · Denominator 48
Pressure ulcers or injuries, new or worsened	2.6%	2.29% 0.3 pts worse	Numerator 2 · Denominator 77 · Adjusted rate 2.72%
Healthcare-associated infections requiring hospitalization	8.3%	7.12% 1.2 pts worse	No Different than the National Rate · Eligible stays 53 · Observed rate 11.32% · Lower 95% interval 4.13%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 139
Staff flu vaccination coverage	33.58%	42% 8.4 pts worse	Numerator 46 · Denominator 137
Discharge function score	60.42%	56.45% 4 pts better	Numerator 29 · Denominator 48
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 37 · Denominator 37
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	21.43%	25.2% 3.8 pts worse	Numerator 9 · Denominator 42

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.0	1.7 0.7 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	1.5 0.3 pts worse	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	88.7%	95.0% 6.3 pts worse	93.4% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 92.9% · Q3 86.6% · Q4 81.6% · 4Q avg 88.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	89.3%	95.0% 5.7 pts worse	95.5% 6.2 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 89.3%
Percentage of long-stay residents experiencing one or more falls with major injury	3.6%	3.1% 0.5 pts worse	3.3% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.3% · Q3 1.5% · Q4 2.6% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.4%	4.1% 2.7 pts better	11.4% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 0.0% · Q4 1.8% · 4Q avg 1.4%
Percentage of long-stay residents who lose too much weight	6.7%	5.5% 1.2 pts worse	5.4% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 11.7% · Q3 5.2% · Q4 4.5% · 4Q avg 6.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	38.1%	19.6% 18.5 pts worse	19.6% 18.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 41.1% · Q2 38.7% · Q3 36.7% · Q4 36.4% · 4Q avg 38.1%
Percentage of long-stay residents who received an antipsychotic medication	10.9%	16.5% 5.6 pts better	16.7% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.8% · Q3 12.5% · Q4 13.5% · 4Q avg 10.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	2.5%	0.1% 2.4 pts worse	0.1% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 4.5% · Q4 2.6% · 4Q avg 2.5%
Percentage of long-stay residents whose ability to walk independently worsened	10.8%	13.9% 3.1 pts better	16.3% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q2 13.8% · Q3 17.8% · Q4 6.9% · 4Q avg 10.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.1%	11.7% 3.6 pts better	14.9% 6.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 8.3% · Q3 6.0% · Q4 5.2% · 4Q avg 8.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.5%	0.9% 0.6 pts worse	1.0% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.3% · Q3 0.0% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.2%	1.7% 0.5 pts worse	1.7% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.5% · Q3 1.5% · Q4 2.6% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.1%	20.4% 3.7 pts worse	19.8% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 26.0% · Q3 26.0% · Q4 19.2% · 4Q avg 24.1%
Percentage of long-stay residents with pressure ulcers	6.0%	5.6% 0.4 pts worse	5.1% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.6% · Q3 5.0% · Q4 8.5% · 4Q avg 6.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	40.6%	82.8% 42.2 pts worse	81.7% 41.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 46.2% · Q2 45.9% · Q3 40.9% · Q4 28.9% · 4Q avg 40.6%
Percentage of short-stay residents who had an outpatient emergency department visit	22.1%	11.5% 10.6 pts worse	12.0% 10.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 25.4% · Expected 12.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.6%	1.3% 0.7 pts better	1.6% 1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	38.8%	79.5% 40.7 pts worse	79.7% 40.9 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 38.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.1%	24.2% 3.1 pts better	23.9% 2.8 pts better	Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 23.7% · Expected 26.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-17 · Fire 2024-12-17

13 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Cycle 2 Health 2024-01-10 · Fire 2024-01-10

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-12-08 · Fire 2022-12-08

18 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-17

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2025-02-05

F · Potential for more than minimal harm 2024-12-17

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2025-02-05

F · Potential for more than minimal harm 2024-12-17

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2025-02-05

F · Potential for more than minimal harm 2024-12-17

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2025-02-05

F · Potential for more than minimal harm 2024-12-17

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2025-02-05

F · Potential for more than minimal harm 2024-12-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-05

F · Potential for more than minimal harm 2024-01-10

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-02-19

E · Potential for more than minimal harm 2024-01-10

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-02-19

Inspection history

Recent health citations

G · Actual harm 2025-08-06

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-08-22

F · Potential for more than minimal harm 2024-12-17

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-02-05

F · Potential for more than minimal harm 2024-12-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-05

F · Potential for more than minimal harm 2024-12-17

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2025-02-05

E · Potential for more than minimal harm 2024-12-17

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-02-05

E · Potential for more than minimal harm 2024-12-17

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2025-02-05

D · Potential for more than minimal harm 2024-12-17

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-02-05

D · Potential for more than minimal harm 2024-12-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-02-05

D · Potential for more than minimal harm 2024-12-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-02-05

D · Potential for more than minimal harm 2024-12-17

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-02-05

D · Potential for more than minimal harm 2024-12-17

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-02-05

D · Potential for more than minimal harm 2024-12-17

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-02-05

C · Minimal harm 2024-12-17

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-02-05

D · Potential for more than minimal harm 2024-08-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-18

E · Potential for more than minimal harm 2024-01-10

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-02-19

E · Potential for more than minimal harm 2024-01-10

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-02-19

D · Potential for more than minimal harm 2024-01-10

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-02-19

D · Potential for more than minimal harm 2024-01-10

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-02-19

D · Potential for more than minimal harm 2024-01-10

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-02-19

D · Potential for more than minimal harm 2024-01-10

F758 · Pharmacy Service Deficiencies

Health

Corrected 2024-02-19

D · Potential for more than minimal harm 2024-01-10

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-02-19

D · Potential for more than minimal harm 2023-07-07

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-08-07

D · Potential for more than minimal harm 2023-03-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-04-25

E · Potential for more than minimal harm 2022-12-08

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-01-17

E · Potential for more than minimal harm 2022-12-08

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2023-01-17

E · Potential for more than minimal harm 2022-12-08