Facility Watch Inspection records for every certified US nursing home

Medilodge of Leelanau

124 West 4th Street
Suttons Bay, MI 49682
(231) 271-1200

CCN
235209
Certified beds
72
Ownership
For profit - Limited Liability company
Chain
Medilodge

Nurse staffing

4.05
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 1.16 hours per resident per day

Nursing staff turnover: 48% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected March 25, 2026

2 citations · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected May 1, 2026
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected May 1, 2026

Inspected January 21, 2026

1 citation · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

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

Past Non-Compliance · corrected January 20, 2026

Inspected December 11, 2024

11 citations · from a complaint investigation · Health
D
F0554 No actual harm with potential for more than minimal harm · Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Deficient, Provider has date of correction · corrected January 14, 2025
D
F0625 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected January 14, 2025
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected January 14, 2025
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 14, 2025
D
F0690 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 14, 2025
D
F0756 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 14, 2025
D
F0809 No actual harm with potential for more than minimal harm · Isolated

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Deficient, Provider has date of correction · corrected January 14, 2025
D
F0887 No actual harm with potential for more than minimal harm · Isolated

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Deficient, Provider has date of correction · corrected January 14, 2025
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected January 14, 2025
F
F0838 No actual harm with potential for more than minimal harm · Widespread

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Deficient, Provider has date of correction · corrected January 14, 2025
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected January 14, 2025

Inspected September 13, 2024

2 citations · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected October 16, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected October 16, 2024

Inspected January 23, 2024

9 citations · from a complaint investigation · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected February 26, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected February 26, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected February 26, 2024
E
F0565 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Deficient, Provider has date of correction · corrected February 26, 2024
E
F0695 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected February 26, 2024
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected February 26, 2024
E
F0809 No actual harm with potential for more than minimal harm · Pattern

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Deficient, Provider has date of correction · corrected February 26, 2024
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected February 26, 2024
F
F0807 No actual harm with potential for more than minimal harm · Widespread

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Deficient, Provider has date of correction · corrected February 26, 2024

Inspected June 1, 2023

3 citations · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 6, 2023
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 6, 2023
E
F0740 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Deficient, Provider has date of correction · corrected July 6, 2023

Inspected December 15, 2022

10 citations · Health
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected January 19, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 19, 2023
D
F0688 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Deficient, Provider has date of correction · corrected January 19, 2023
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 19, 2023
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected January 19, 2023
E
F0726 No actual harm with potential for more than minimal harm · Pattern

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Deficient, Provider has date of correction · corrected January 19, 2023
E
F0759 No actual harm with potential for more than minimal harm · Pattern

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected January 19, 2023
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected January 19, 2023
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected January 19, 2023
F
F0842 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected January 19, 2023

Ownership transfers

EffectiveSellerBuyer
02/01/2018FMG West Fourth Street Michigan LLCLeelanau Opco LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.