Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Macomb Post Acute Care Center during CMS and state inspections, most recent first.
A resident with bowel incontinence and intact cognition did not receive dignified incontinence care. The resident, family, and facility leadership reported delayed brief changes, rough handling during hygiene care, and staff making the resident feel embarrassed and at fault for being incontinent. The resident stated he had waited a long time to be cleaned up and had sat in a soiled brief for an hour, which caused him shame and mental anguish.
Failure to provide correct, palatable meals and adequate portions. Residents reported repeated problems with cold food, missing menus, incorrect menu items, and very small portions. Complaints and interviews described meals that did not match the menu, lack of substitutions, and food that was lukewarm, hard, or served without expected items such as protein. The resident council president and family members also reported ongoing dissatisfaction with meal quality and quantity, and a former dietary cook stated that menus and substitutions were not consistently followed.
Kitchen sanitation and food labeling deficiencies: Surveyors observed sticky debris on walk-in cooler/freezer and prep refrigerator door handles, debris on kitchen and cooler floors, and multiple improperly stored food items in the prep refrigerator, including open undated beverages, partially uncovered food, and containers lacking names or dates. The Dietary Mgr stated floors were usually mopped once a month and refrigerator/freezer handles were cleaned about weekly; the Admin also noted the kitchen floors were sticky.
Delayed response to resident call lights. Multiple alert and oriented residents reported that call lights were often unanswered for long periods, sometimes over an hour, and a resident council president said the issue had been ongoing for quite some time. Family members also observed call lights left on without staff response, and an ombudsman reported working on the issue. The administrator acknowledged the facility knew there was a problem with call light response.
Failure to Report Abuse and Neglect Allegations: The facility did not report multiple abuse and neglect allegations to the abuse coordinator or state agency. A resident and family reported rough peri care, bruising, and delayed care, including a bruised testicle after staff care and concerns about poor hygiene, bruises, and long wait times. The AIT, who served as the abuse coordinator, confirmed the allegations were not reported as required.
Failure to Investigate Abuse and Neglect Allegations: The facility did not thoroughly investigate multiple abuse/neglect concerns involving residents, including rough peri care, a CNA grabbing a resident’s testicle and causing bruising, and unexplained bruising with family complaints of poor care. Records lacked detailed incident documentation, staff/resident interviews, and investigation notes, and the DON/AIT confirmed the allegations were not fully investigated or documented.
A cognitively impaired resident with a high elopement risk exited through alarmed doors and was not identified as missing until police called the facility after the resident was found wandering on a main street. The resident had dementia and other diagnoses, used an ankle alarm, and had prior exit-seeking behavior documented. The report states a non-medical staff member silenced the door alarm without staff knowledge, the resident was last seen near the front lobby, and required ER evaluation before returning to the facility.
A resident with an order for fentanyl patch 75 mcg/hr every 72 hours had repeated problems with refill prescriptions for the controlled medication. Staff reported contacting the physician when only one or two patches remained, and the spouse said she had brought multiple patches from home because the facility could not get the prescription filled in time. On one occasion, the MAR lacked documentation that the patch due that morning was applied, pharmacy delivery was delayed, and the spouse brought in a patch that was then placed on the resident.
A multidose vial of Aplisol (Tuberculin) used for all residents was found opened and undated in the medication room refrigerator. An LPN confirmed the vial was not dated as required by facility policy, which states that multidose vials should be dated when opened and discarded after 30 days.
The facility did not provide appropriate food substitutions for residents who declined the vegetables or entrees served at meals. Only one vegetable and one entree were offered daily, and the substitution menu lacked vegetable options. Residents and staff confirmed that no alternatives were available for vegetables, and the only entree substitutes were hot dogs, corn dogs, or grilled cheese. This practice affected all residents and did not align with the facility's own substitution policy.
Surveyors found that staff failed to document cool-down temperatures for cooked meats, did not maintain proper milk storage temperatures, used a sanitizing solution with no detectable quaternary ammonium, and did not ensure that kitchen staff with beards wore appropriate hair restraints. These failures in food safety, sanitation, and personal hygiene protocols had the potential to affect all residents in the facility.
A resident with Adult Failure to Thrive and related nutritional risks was not given physician-ordered double meal portions as documented in their care plan and dietary slip. Instead, the resident received only single portions and was told to request seconds after others were served, often resulting in no additional food being available. Dietary staff were unaware of the order, and the DON confirmed that double portions should have been provided automatically.
A resident experienced a fall resulting in a left hip fracture, and the facility failed to provide timely pain management. Despite the resident's complaints of severe pain, no pain assessment or medication was documented for seven hours post-fall. The LPN on duty did not reassess the resident due to a busy night, and the care plan lacked focus on pain management. The Medical Director highlighted the need for pain assessment after such incidents.
A resident experienced a fall resulting in a head injury, but the attending LPN failed to initiate neurological checks or notify the physician and family, as required by protocol. The incident was dismissed as a behavior issue, despite the resident's seizure history. The following morning, another LPN discovered the injury, leading to the resident's hospital transfer. Staff interviews revealed communication and protocol adherence failures.
The facility failed to maintain the walk-in cooler at the required temperature, leading to unsafe food storage conditions. Despite attempts to fix the issue by adding freon, the cooler continued to malfunction, with temperatures reaching 47 degrees Fahrenheit. Food items stored in the cooler were above safe temperature limits, and residents reported receiving warm and spoiled milk. The cooler was eventually shut down, but not before the deficiency potentially affected all 50 residents.
A resident with a left foot wound did not receive proper wound care as a nurse failed to follow the facility's Clean Dressing Change Policy. The nurse did not change gloves or perform hand hygiene before cleansing the wound and touched dressing materials with bare hands. The incident was confirmed by the nurse and facility management.
A facility failed to ensure a resident had physician orders and a diagnosis for an indwelling urinary catheter. The resident's catheter tubing was observed resting on the ground and dragging across surfaces, with dark amber urine and sediment noted. Staff acknowledged the catheter should not touch the ground, and the facility's administration confirmed the lack of orders and were investigating the necessity of the catheter.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with open wounds, indwelling urinary catheters, and a PICC line. Despite the facility's policy requiring EBP for such conditions, staff did not wear gowns during treatments, and necessary signage and PPE bins were absent. Interviews revealed a misunderstanding among staff regarding the criteria for EBP, leading to inadequate infection control measures.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
The facility failed to ensure a resident with known bowel incontinence received dignified incontinence care. The resident had diagnoses including Adult Failure to Thrive, Calculus of Gallbladder, Type 2 Diabetes Mellitus, and Generalized Anxiety Disorder, and the Minimum Data Set documented intact cognition, continence of bladder function, always incontinent of bowel function, and a need for substantial to maximal assistance with toileting and hygiene. The facility’s dignity policy required residents to be treated with dignity and respect at all times and to receive prompt toileting assistance, and the incontinence care policy stated its purpose was to provide cleanliness and comfort, prevent infection and skin irritation, and observe skin conditions. The resident’s progress note documented that he refused to get up and use the toilet for bowel movements and preferred to be incontinent and have CNAs clean him up after he had gone in his brief. The resident and his family reported that staff did not change him promptly, that he waited hours to be cleaned up, and that staff were rough during care. The resident stated he had sat in a soiled diaper for an hour, that staff got mad at him about it, and that he felt embarrassed and ashamed because he could not control his bowels and felt like he was inconveniencing staff. The administrator in training and regional administrator confirmed the resident had been incontinent of bowel since admission and stated it was not acceptable for staff to make him feel ashamed or at fault for being incontinent.
Failure to Provide Correct, Palatable Meals and Adequate Portions
Penalty
Summary
The facility failed to provide scheduled menu items, palatable food, appropriate food temperatures, and resident-preferred portion sizes during dining services. The resident roster documented 58 residents in the facility, and the facility policy required each resident to receive the correct diet with preferences accommodated as feasible, with staff checking tray cards before serving food. The dietary job descriptions also required food to be prepared and served in a safe and palatable manner and for the Food Service Director to ensure menu compliance and resident food preferences were addressed. The grievance log and complaint forms documented repeated resident concerns about missing menus, lack of substitution options, cold meals, incorrect menu items, and small portions. One resident reported not receiving menus before meals, meals arriving cold, and feeling that rights were being violated. Another complaint stated that the food was not good, that a salad was sent for a hot meal, and that food was served cold. Additional complaints described meals being cold all the time, actual meals not matching menus, portions being very small, and residents not receiving protein or complete hot meals. One resident reported receiving only an egg instead of a fried egg sandwich, and another stated that a recent meal did not include protein. During interviews, residents and family members described ongoing dissatisfaction with food quality, temperature, and portion size. One resident stated the food was rotten, slop, and usually lukewarm, with only one bite of chicken served on one occasion. The resident council president stated that food complaints were common, menus were not followed, and residents did not get enough food. Another resident reported food being too hard or cold, potatoes being hard, and a room tray arriving with lettuce instead of the ordered meal. Family members stated they regularly brought food in because the facility food was so bad and portions were not enough. A former dietary cook stated that meals were sometimes substituted, meal tickets were sometimes lost, and the cook had been written up for not following menus and substitutions.
Kitchen sanitation and food labeling deficiencies
Penalty
Summary
The Facility failed to maintain clean kitchen floors, clean walk-in cooler and refrigerator units, clean refrigerator handles, and proper labeling and dating of opened food items in the food preparation refrigerator. On 7/23/26 at 10:10 am, surveyors observed the walk-in refrigerator and walk-in freezer door handles with a substantial amount of thick sticky substance and debris in the handle crevices, along with moderate debris on the floors. The floors of the walk-in refrigerator, walk-in freezer, and kitchen had a heavy tactile resistance, causing the soles of the surveyor's shoes to stick and adhere to the floor. During the same observation, the stand-up food preparation refrigerator had thick sticky substance and debris on the handles and contained multiple improperly stored items, including an open undated bottle of 16-ounce soda with no name, a container of gravy dated 7/13/26, coleslaw dated 7/17/26, nine individual serving bowls of whipped fruit salad that were partially uncovered and had no date, and an open container of half-n-half dated 7/15/26. On 7/25/26 at 8:31 am, surveyors again observed sticky debris on the walk-in refrigerator, walk-in freezer, and stand-up food preparation refrigerator door handles, and the stand-up refrigerator also contained two open undated bottles of 16-ounce soda with no name and French salad dressing containers dated 2/8/26 and 6/9/26. The Dietary Manager stated the floors were usually mopped once a month and that the outside of the refrigerator and freezer handles were cleaned about every week, and the Administrator stated the kitchen floors were sticky and needed to be cleaned.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner and failed to comply with resident requests for assistance for five of seven residents reviewed for call light response. The facility’s call bell policy stated that residents must be able to call for staff assistance from bedside, toilet, and bathing areas, that calls for assistance shall be answered timely, and that any staff member who hears or sees an alert is responsible to answer within a reasonable timeframe. Despite this, the record included repeated resident council concerns and grievance documentation about lights not being answered in a timely manner, including concerns that call lights were not being answered on second and third shift. During interviews, multiple alert and oriented residents reported long delays in getting help after activating call lights. One resident stated the call light took forever to be answered, another said call lights often took over an hour, and another reported waits of a half-hour to an hour. A resident council president stated the issue had been ongoing for quite some time. Family members also reported seeing call lights remain on for over an hour without staff checking on the residents, and one spouse stated the resident was lucky to have family present to help and that water was sometimes not provided because staff had not yet come in. The ombudsman stated he had been working on the call light issues at the facility, and the administrator acknowledged the facility knew there was an issue with call lights.
Failure to Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure allegations of resident abuse and neglect were reported to the abuse coordinator and the state agency for three residents reviewed for abuse. The facility policy stated that allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property must be reported in the proper time frame, and that investigation results must be reported to the administrator or designated representative and to the state agency within five working days of the incident. The facility's Administrator in Training stated she had not received any reported abuse allegations since starting in her role and confirmed she was the facility's abuse coordinator. For one resident, the family reported that staff were rough during care and that the resident's testicle was bruised after being squeezed during cleaning. The resident stated a CNA grabbed his testicle, squeezed until he was bruised, and that another CNA laughed about it. The resident also stated the physician assistant examined his genitals and confirmed the bruise, and a progress note documented examination for a bruise to the testicle and acute onset of pain after cares were provided by staff. The resident denied ever talking to the Administrator in Training about the incident, and the CNA continued to provide care. For another resident, a grievance form documented that a CNA needed to be more gentle with peri care, and the resident stated the CNA was too rough and entered places she should not have during care. The resident said she complained during the incident and that the CNA no longer provided care for her, but the Administrator in Training stated she treated the matter as a customer service concern and did not report it to the state agency. For a third resident, a family member completed a complaint form stating the resident was not getting proper care, did not get weekly baths, took too long to be changed, had more bruises than she should, and experienced long call light wait times and pain. The Administrator in Training stated she was made aware of these concerns but did not report the allegations included in the complaint to the state agency.
Failure to Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure allegations of resident abuse and neglect were investigated and that residents were immediately protected from further potential abuse for three residents. The facility’s abuse policy stated that all alleged violations must be thoroughly investigated, further potential abuse must be prevented while the investigation is in progress, and results must be reported to the administrator and state agency as required. The administrator in training stated she had no abuse allegations or investigations since starting in the role, despite multiple resident and family concerns documented in the record and described during interviews. For one resident, family and the resident reported that a CNA was rough during hygiene care, grabbed the resident’s testicle, and caused bruising and pain. The resident stated the CNA and another CNA laughed after the incident, and the physician assistant examined the resident’s genitals and confirmed a bruise. The resident’s record documented the exam for bruising and acute onset of pain after care, but did not contain detailed notes, skin assessments, an incident narrative, or an investigation related to the genital bruising and pain. The DON stated there were no further records, interviews, or evaluation to determine the cause and details of the injury. For another resident, the record included a grievance stating that a CNA needed to be more gentle with peri care and that the resident did not want that CNA to care for her anymore. The resident stated the CNA was too rough, hurt her during peri care, and entered places she should not have, and that another CNA heard her complaints. The only written staff statement obtained was from the CNA involved, and the administrator confirmed there was no abuse investigation, no additional staff or resident interviews, and uncertainty about whether the CNA was suspended pending investigation. For a third resident, a family member reported poor care, delayed bathing and changing, and more bruises than expected, and a nursing note documented a bruise to the forehead with the resident unable to explain its cause. The administrator confirmed she was aware of the family complaint but did not record statements, interview staff or residents, or complete an investigation, and the resident’s record contained no detailed notes or investigation addressing the allegations.
Failure to Prevent Resident Elopement Through Alarmed Exit Doors
Penalty
Summary
The facility failed to provide adequate supervision and prevent a cognitively impaired resident with identified exit-seeking behavior and a high elopement risk from leaving the facility through alarmed doors. The resident exited unsupervised, wandered approximately 0.4 miles down a main street with continuous traffic, and was later found by police standing on a corner waving down traffic for help. The resident had an ankle alarm device, and police called the facility 45 minutes after the resident left to confirm identity. The resident required an emergency room evaluation and then returned to the facility without injury. The resident involved had diagnoses including unspecified dementia, conversion disorder with seizures, anxiety disorder, history of falling, and transient alteration of awareness. The resident’s MDS documented moderate cognitive impairment, and wandering/elopement risk assessments identified the resident as high risk on multiple occasions. Prior progress notes documented the resident attempting to leave by following a visitor out of the facility, and an alarm device was placed. The care plan included use of an alarm device, staff awareness of the resident’s location, and increased checks after the elopement. The investigation and interviews showed the facility was unaware the resident had left until police notified staff. Staff stated the resident was last seen near the front nurse’s station/front lobby area, and the facility did not identify the resident as missing before police contact. The report also states that a non-medical staff member silenced the exit door alarm without staff knowledge. In addition, ordered alarm placement and function checks were not consistently documented, and the CNA task documentation lacked required 15-minute and/or 2-hour monitoring documentation for the resident. The facility’s investigation did not identify a root cause for the elopement.
Failure to Obtain Timely Refill Prescriptions for Fentanyl Patch
Penalty
Summary
The facility failed to have adequate processes in place for acquiring and receiving refill prescriptions for a narcotic medication for one resident. The resident’s record showed admission diagnoses including opioid dependence uncomplicated, depression, type 2 diabetes mellitus without complications, heart failure, and other orthopedic aftercare, and the physician order dated 1/30/25 included Fentanyl patch 75 mcg/hr every 72 hours for pain with removal per schedule. The facility policy stated that controlled substances require special ordering, receipt, and recordkeeping, and that a chart order is not equivalent to a prescription for controlled drugs. The resident’s MAR for 4/10/26 showed the fentanyl patch due at 9:07 a.m. with no documentation that it was applied. Progress notes documented that pharmacy was called and the patches would be delivered in that night’s shipment, but the facility was unable to pull from backup, and later that day the resident’s wife brought in a fentanyl patch and it was placed on the resident’s left rear shoulder. The RN stated that when fentanyl patches are down to one or two remaining, nursing contacts the physician for a new prescription, and the spouse reported bringing a total of 11 fentanyl patches to the facility since admission because of problems getting the prescription filled. The DON stated the facility had difficulty obtaining controlled substance prescriptions from the physician in a timely manner and that staff had not contacted the Medical Director for assistance because they did not want to upset the community doctors.
Undated Multidose Tuberculin Vial Found in Medication Storage
Penalty
Summary
A multidose vial of Aplisol (Tuberculin) was found in the medication room refrigerator, opened and partially used, without being dated at the time of opening. The facility's policy requires that all medications, including those requiring refrigeration, be labeled and stored according to specific guidelines, and that multidose vials be dated when opened. During observation, an LPN confirmed that the vial was not dated and acknowledged that it is used for all residents in the facility. The LPN also stated that the tuberculin vial should be dated upon opening and discarded after 30 days, in accordance with facility policy. At the time of the survey, 60 residents resided in the facility.
Failure to Offer Nutritive Food Substitutions and Vegetable Alternatives
Penalty
Summary
The facility failed to provide food substitutions of similar nutritive value for residents who did not want or could not eat the vegetables or entrees served at meals. Observations showed that only one vegetable and one entree option were available daily for lunch and supper, and the substitution menu did not include any vegetable alternatives. The only substitutes offered for main entrees were hot dogs, corn dogs, or grilled cheese, with no comparable options for vegetables. During meal service, residents who did not like the vegetables served were not offered any alternative, and staff confirmed that no vegetable substitutions were available. Multiple residents reported that they consistently received only one choice for lunch and supper, and if they did not want the main entree, their only options were limited to the same few items. Residents also stated that they were never offered a substitute for vegetables and often left them uneaten. Staff interviews confirmed that substitutions for vegetables were not provided, and the facility's substitution policy was not followed regarding offering alternatives that consider residents' likes and dislikes. These failures had the potential to affect all 60 residents in the facility.
Failure to Follow Food Safety, Sanitation, and Personnel Hygiene Protocols
Penalty
Summary
The facility failed to adhere to food safety and sanitation protocols in several key areas, as observed during a kitchen and dining room tour. Cooked meats, including sausage patties, chicken breasts, and polish sausages, were stored in the refrigerator without any documentation of required cool-down temperatures. The dietary manager confirmed that cool-down logs were not maintained for these items, despite having received logs from the health department. Additionally, a gallon of milk was found stored at 49 degrees Fahrenheit, above the required 41 degrees or below, due to improper placement on ice. Sanitation procedures were not properly followed, as evidenced by the use of a sanitizing bucket with zero parts per million (PPM) of quaternary ammonium, well below the required 200-400 PPM. Staff members responsible for preparing the sanitizing solution were unaware of the need to add sanitizer, and this was confirmed by both the dietary aides and the dietary manager. The facility's policies require the use of properly diluted sanitizing solutions for cleaning food contact surfaces, but these were not implemented during the survey. Personnel hygiene standards were also not met, with multiple dietary aides observed working in the kitchen with full beards that were not restrained by hair nets, contrary to facility policy. Staff members admitted to not knowing that beard restraints were required. These lapses in food safety, sanitation, and personal hygiene protocols had the potential to affect all 60 residents residing in the facility, as documented in the facility's census.
Failure to Provide Physician-Ordered Double Meal Portions for Resident with Failure to Thrive
Penalty
Summary
A resident with diagnoses of Anorexia, Adult Failure to Thrive, and Protein-Calorie Malnutrition was not provided with physician-ordered double meal portions as required by their care plan and physician orders. The resident's dietary slip and physician order sheet both documented the need for double portions and cottage cheese with lunch and supper, with the option for additional helpings if needed. Despite these orders, observations showed that the resident consistently received only single portions at meals. The resident reported that dietary staff instructed him to wait until others were served before requesting a second portion, which often resulted in no additional food being available. Interviews with dietary staff confirmed that double portions were not routinely provided, and staff were unaware of the physician's order for double portions. The Director of Nursing acknowledged that the resident's dietary order required double portions to be served without the resident having to request them. These actions and inactions led to the resident not receiving the prescribed nutritional support necessary for his medical condition.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R2, who experienced a fall resulting in a left hip fracture. The incident occurred when R2 fell while attempting to turn on the television, and was found on the floor by a CNA, V6, who reported hearing a loud thud. Despite R2's complaints of pain throughout the night, no pain assessment or management was documented until the following morning, approximately seven hours after the fall. The facility's policy on pain management and change in condition procedures were not followed. The LPN, V3, who responded to the fall, did not conduct a thorough assessment or document R2's pain, relying instead on the CNA to report any issues. V3 admitted to not reassessing R2 due to a busy night and failed to document the pain on the neuro sheet. Consequently, no pain medication was administered to R2 during the night, as confirmed by the Medication Administration Record. R2's care plan did not include any focus on pain management, and there was no documentation of pain assessment or interventions from the time of the fall until the morning. The lack of documentation and pain management was further highlighted by the Medical Director, V11, who emphasized the importance of assessing pain after a fall, especially given R2's history of a previous hip fracture. This oversight resulted in R2 experiencing severe pain without appropriate intervention for an extended period.
Failure to Provide Post-Fall Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care following a fall incident involving a resident, identified as R1. After R1 was found on the floor with a small amount of blood on his head, the attending LPN, V3, conducted a superficial assessment and did not initiate neurological checks or notify the physician and family, as required by the facility's fall protocol. V3 dismissed the incident as a behavior issue, despite R1's history of seizures, and did not perform further checks throughout the night. The following morning, another LPN, V8, was informed by a CNA, V4, that R1 had a bleeding bump on his head. Upon assessment, V8 found a significant bruise and laceration on R1's head, with blood on the pillowcase. R1 was then transferred to the hospital, where he was diagnosed with a scalp contusion. The night shift CNA, V6, had reported the bleeding to V3, but no further action was taken. Interviews with staff revealed a breakdown in communication and adherence to protocol. V3 did not believe R1 had fallen and failed to follow the necessary steps outlined in the facility's fall protocol. The facility's administrator and medical director emphasized the importance of following protocol regardless of a resident's behavioral history, highlighting the deficiency in care provided to R1.
Failure to Maintain Safe Food Storage Temperatures
Penalty
Summary
The facility failed to maintain the walk-in cooler in the kitchen at the required temperature of less than 40 degrees Fahrenheit, with the cooler consistently running at temperatures above this threshold. This issue persisted despite multiple attempts to address it by adding freon, which proved to be an ineffective solution. The facility's policy required immediate corrective action when temperatures were out of range, but the necessary repairs were delayed, and the cooler continued to be used despite its malfunction. During a tour of the kitchen, it was observed that the walk-in cooler's temperature was reading as high as 47 degrees Fahrenheit. The cooler contained various food items, including yogurt, eggs, cheese, and milk, which were not stored at the appropriate temperatures. The dietary manager and maintenance director acknowledged the cooler's malfunction and the inadequate temporary measures taken, such as keeping the freezer door open to cool the walk-in cooler. Despite these efforts, food items were found to be above the safe temperature limit, leading to the disposal of some items. Residents reported receiving warm and spoiled milk, indicating that the issue had been ongoing and affecting the quality of food served. The facility's failure to promptly repair the cooler and find alternative storage solutions for perishable items resulted in the potential risk of serving unsafe food to residents. The walk-in cooler was eventually shut down, and the remaining food items were removed, but not before the deficiency had the potential to impact all 50 residents in the facility.
Improper Wound Care and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its Clean Dressing Change Policy during the wound care of a resident with a left foot wound. The resident, who was admitted with conditions including Osteomyelitis, Type 2 Diabetes Mellitus with Foot Ulcer, and Necrotizing Fasciitis, required careful wound management to prevent infection. During an observed dressing change, a registered nurse (V8) did not remove soiled gloves or perform hand hygiene before cleansing the wound. V8 also touched wound dressing materials with bare hands and failed to wash hands before handling clean items after the procedure. The incident was confirmed by V8, who acknowledged the failure to change gloves and perform hand hygiene as required by the facility's policy. The nurse admitted to touching the Calcium Alginate dressing with bare hands and not washing hands immediately after the wound care. The facility's administrator and director of nursing confirmed that V8 should have followed proper hand hygiene and glove use protocols to prevent potential infection and cross-contamination.
Failure to Ensure Proper Use and Maintenance of Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident had physician orders and a diagnosis for the use of an indwelling urinary catheter. The resident, who was discharged from the hospital after a femur fracture repair, did not have documented orders for an indwelling urinary catheter upon admission to the skilled nursing facility. The resident's current physician orders also lacked documentation for the catheter, including its size and bulb inflation. Despite this, the resident's care plan noted the presence of an indwelling urinary catheter and ongoing antibiotic therapy for a urinary tract infection. Additionally, the facility failed to prevent the resident's indwelling urinary catheter from coming into direct contact with the ground. Observations revealed that the catheter tubing was resting on the ground and dragging across surfaces, both inside and outside the facility. The urine in the tubing was noted to be dark amber with thick brown sediment. Staff members acknowledged that the catheter should not touch the ground and that the resident frequently attempted to pull it out. The facility's administrator and director of nursing confirmed the lack of orders for the catheter and were investigating the necessity of its use.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with open wounds, indwelling urinary catheters, and a peripherally inserted central catheter (PICC). The facility's policy, dated 3/27/24, mandates the use of EBP to prevent the transmission of infectious organisms, particularly for residents with chronic wounds or indwelling medical devices. However, observations revealed that the facility did not adhere to these guidelines for residents R1, R4, and R6, who were identified as needing EBP. Resident R1 had a PICC line for intravenous antibiotics and required daily wound care for gangrene, osteomyelitis, and necrotizing fasciitis. Despite this, staff did not wear gowns during treatments, and no EBP signage or personal protective equipment (PPE) bins were present outside R1's room. Similarly, residents R4 and R6, both with indwelling urinary catheters, did not have EBP implemented, and their rooms lacked the necessary signage and PPE bins. Staff members, including registered nurses and certified nursing assistants, were observed performing care without the required protective measures. Interviews with facility staff, including the Administrator, Director of Nursing, and Infection Preventionist, confirmed the lack of EBP implementation for these residents. The Infection Preventionist incorrectly believed that a PICC line or an indwelling urinary catheter alone did not warrant EBP. This misunderstanding led to the absence of necessary precautions, as evidenced by the lack of signage and PPE outside the residents' rooms and the staff's failure to wear gowns during high-contact care activities.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 48 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Macomb
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elms, The | 0.1 mi | ★★★★★ | 15 | 0 |
| Wesley Village | 0.4 mi | ★★★★★ | 4 | 0 |
| Countryside Care Center | 0.7 mi | ★★★★★ | 20 | 0 |
| Goldwater Care Roseville | 15.2 mi | ★★★★★ | 0 | 0 |
| Rushville Nursing & Rehab Ctr | 23.4 mi | ★★★★★ | 9 | 2 |
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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 October 2026) and official state health department websites.