Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allegan County Medical Care Facility during CMS and state inspections, most recent first.
Untimely MDS Transmission: A resident’s Quarterly MDS was completed but not accepted for transmission to CMS because it was not closed correctly. The DON confirmed the assessment had not been exported, and both the MDSC and DON deferred to each other when asked how MDS transmissions were tracked for timeliness.
Failure to provide ADL care, including nail care, for a dependent resident. A resident with hemiplegia, vascular dementia, and moderate cognitive impairment had black debris caked under the thumbnail and pointer finger on the right hand during repeated observations. The care plan directed staff to check, trim, and clean nails on bath day and as needed, and staff reported the resident did not refuse nail care and liked receiving it.
A resident with obstructive sleep apnea had a care plan for BiPAP use with oxygen while asleep, but the physician order set did not include the time or frequency of BiPAP administration. The MAR/TAR also had no documentation showing BiPAP therapy was administered, and the DON and RN confirmed the order was incomplete and that the record lacked a check-off for the therapy.
The facility's kitchen was found to have several deficiencies in food safety and sanitation. A stand-up mixer was not cleaned properly, and cooling logs for various foods showed non-compliance with temperature guidelines. Pre-cooked bacon was uncovered in the freezer, and a disinfectant solution exceeded the allowable concentration. Expired yogurts were also found in the refrigeration unit, all of which could lead to foodborne illness among residents.
A facility failed to develop a comprehensive care plan for a resident prescribed Eliquis for atrial fibrillation. The care plan lacked focus, goals, or interventions for the anticoagulant use. The DON, who recently took over the role, acknowledged the oversight and the importance of care planning for high-risk medications due to bleeding risks.
The facility failed to maintain proper infection control practices for two residents on Enhanced Barrier Precautions. A CNA did not change gloves or perform hand hygiene during care for a resident with a J-tube and Foley catheter, risking cross-contamination. Additionally, an OTA assisted another resident with arm exercises without wearing PPE, despite requirements for high-contact activities. These deficiencies highlight lapses in PPE use and hand hygiene, potentially spreading bacteria.
The facility did not update the daily nurse staffing information for three days, affecting all residents. The Resident Care Labor Hours document was outdated, and the responsibility for posting it was unclear during the Staffing Scheduler's vacation. The NHA admitted to forgetting to post the information.
The facility did not update its pneumococcal vaccination policy to include current standards, such as PCV15, PCV20, and PCV21 vaccines, as recommended by ACIP. The outdated policy, last revised in 2018, only included PCV13 and PPSV23, potentially leaving residents at risk of not receiving appropriate vaccinations. The Infection Preventionist confirmed the use of the outdated policy, highlighting a significant deficiency in the facility's immunization practices.
The facility failed to properly store clean and sanitary items, maintain laundry equipment, and clean resident shared equipment, leading to an increased risk of contamination. Observations revealed dust and debris in linen closets, improper storage of hygiene products, and soiled activity supplies. Staff reported no set schedule for cleaning shared items, and the infection preventionist and activity director confirmed the lack of a cleaning schedule.
A facility failed to develop a baseline care plan within 48 hours for a resident with hemiplegia and hemiparesis following a stroke. The resident was observed not initiating eating, and staff were unsure of the required assistance and transfer methods due to the absence of a baseline care plan.
The facility failed to develop and implement person-centered care plans for two residents, one with skin shearing and another with PTSD triggers. Despite staff awareness, the care plans were not updated to reflect the residents' current conditions, indicating a systemic issue in care planning.
Untimely MDS Transmission
Penalty
Summary
The facility failed to ensure that Resident #21’s Minimum Data Set (MDS) assessment was transmitted to CMS within the required timeframe. Resident #21 was a female admitted to the facility on [DATE], and review of her electronic medical record showed that her 12/9/25 Quarterly MDS was completed but was not marked as accepted, indicating it had not been transmitted to CMS. During interview, the MDS Coordinator reported that the DON had previously been the MDS Coordinator and was still the person who exported completed MDS assessments to CMS. The DON reviewed the assessment and confirmed that the 12/9/25 Quarterly MDS had not been transmitted because it was not closed correctly and she had missed the error. The DON also stated that if an MDS is not submitted timely, CMS may not have an accurate reflection of the resident’s status. When asked how MDSs were tracked to ensure timely transmission, the MDS Coordinator deferred to the DON, and the DON deferred back to the MDS Coordinator.
Failure to Provide Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide ADL care, including nail care, for a dependent resident. Resident #3 was a female with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, vascular dementia with psychotic disturbance, and major depressive disorder. Her MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and functional limitations in range of motion on one upper extremity and both lower extremities. Her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, and to report changes to the nurse. During observation and interview, Resident #3 stated she liked having her nails done, but her right thumbnail and pointer finger were observed with black debris caked underneath the nails. The same condition was observed again the following day. A CNA reported the resident did not refuse nail care and liked receiving it. Another CNA stated nail care was typically provided when it was noticed that nails were dirty. The DON stated residents' nails should be cleaned on shower day at least weekly and whenever they were dirty, and that visibly dirty nails should absolutely be cleaned.
Incomplete BiPAP Order and Missing Administration Documentation
Penalty
Summary
A deficiency was cited for failure to ensure a complete physician order was in place for BiPAP therapy and for failure to document BiPAP therapy administration for one resident reviewed for respiratory care. The resident was a female with obstructive sleep apnea, and her care plan stated that she used a BiPAP with oxygen while asleep. The current physician orders included BiPAP settings and a separate order to clean and store the BiPAP in the morning, but the order summary did not contain an order specifying the time or frequency of BiPAP administration. Review of the resident’s January 2026 MAR/TAR and February 2026 MAR/TAR showed no documentation of BiPAP therapy administration. During interview, the DON stated there was no order in place for the time or frequency of BiPAP therapy and that nursing staff would not know what to do without a complete order. The RN stated the resident normally put her BiPAP on when getting ready for bed and that there should be a section in the medical record to check off when the therapy was administered.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. A stand-up mixer was found with dried crusted debris, indicating it was not cleaned properly. The facility's cooling logs for various foods, including stuffed pepper soup, minestrone soup, and turkey, showed that the foods did not reach the required temperatures within the specified time frames, as per the 2022 FDA Food Code. Additionally, pre-cooked bacon was found uncovered in the freezer, which is against the guidelines for food protection from cross-contamination. Further observations revealed that a disinfectant solution stored on the kitchen counter exceeded the maximum allowable concentration, posing a risk of chemical contamination. Expired blueberry and strawberry yogurts were also found in the refrigeration unit, which violates the FDA Food Code's requirements for the disposition of ready-to-eat, time/temperature control for safety food. These deficiencies collectively have the potential to result in foodborne illness among residents consuming food prepared in the facility's kitchen.
Failure to Implement Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed Eliquis, an anticoagulant, for unspecified atrial fibrillation. The resident's care plan did not include any focus, goals, or interventions related to the use of this high-risk medication. The Director of Nursing (DON), who had recently assumed the position and was previously the MDS Coordinator, acknowledged the absence of a care plan for the anticoagulant use and confirmed that it was necessary due to the high risk of bleeding associated with such medications. The deficiency was identified during a review of the resident's care plan and an interview with the DON.
Infection Control Deficiencies in PPE and Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain safe infection control practices during direct care for Resident #4, who was on Enhanced Barrier Precautions due to a history of extended-spectrum-beta-lactamase in urine, a J-tube, and a Foley catheter. During an observation, two CNAs were providing a bed bath and incontinence care for the resident. Although they donned gowns and gloves, one CNA did not change gloves or perform hand hygiene when moving from dirty to clean tasks, such as after cleaning the resident's anal area and handling the J-tube. This lack of proper glove use and hand hygiene during care activities posed a risk of cross-contamination. For Resident #12, the facility did not ensure that all staff consistently donned proper PPE prior to conducting high-contact activities. Resident #12 was on Enhanced Barrier Precautions due to intermittent catheterization and a history of recurrent UTIs and urosepsis. An Occupational Therapy Assistant was observed assisting the resident with arm exercises without wearing any PPE, despite the requirement for gowns and gloves during high-contact activities. The OTA incorrectly believed that PPE was only necessary when touching the resident's catheter. The observations revealed a lack of adherence to infection control protocols, specifically regarding the use of PPE and hand hygiene during high-contact activities with residents on Enhanced Barrier Precautions. These deficiencies were identified through observations and interviews, highlighting the potential for cross-contamination and the spread of bacteria within the facility.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information for three consecutive days, affecting all 33 residents. On 2/10, 2/11, and 2/12, the Resident Care Labor Hours document displayed in the common area near the nurse's station was outdated, showing the date 2/7. This document should have been updated daily to reflect the current staffing levels of CNAs and nurses for each shift. The Director of Nursing (DON) indicated that the Staffing Scheduler was responsible for this task but was on vacation, and there was no clear delegation of responsibility in their absence. The Nursing Home Administrator (NHA) admitted to being responsible for posting the information during the Staffing Scheduler's absence but forgot to do so on the specified dates.
Failure to Update Pneumococcal Vaccination Policy
Penalty
Summary
The facility failed to update its policies and procedures regarding pneumococcal immunizations to align with current standards of practice. The existing policy, last revised in June 2018 and reviewed in September 2023, only included recommendations for PCV13 and PPSV23 vaccines based on age and susceptibility. However, it did not incorporate the updated recommendations from the Advisory Committee on Immunization Practices (ACIP) that include the use of PCV15, PCV20, and PCV21 vaccines. This oversight resulted in the potential for eligible residents to not be offered the appropriate pneumococcal vaccines, thereby increasing their risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. During an interview, the Infection Preventionist confirmed that the 2018 policy was still in use as the facility's current pneumococcal policy. The CDC report from January 2025 highlighted that before October 2024, ACIP recommended the use of a pneumococcal conjugate vaccine for all adults aged 65 years and older who had not received a PCV or whose vaccination history was unknown. The report also noted expanded recommendations for PCV20 or PCV21 for adults who began their vaccination series with PCV13. The facility's failure to incorporate these updated guidelines into their policy represents a significant deficiency in their immunization practices.
Failure to Maintain Clean and Sanitary Conditions
Penalty
Summary
The facility failed to properly store clean and sanitary items, maintain laundry equipment, and clean resident shared equipment, leading to an increased risk of contamination. During a tour, it was observed that the Hillcrest North linen closet had an accumulation of dust and debris under the bottom open wire racks, exposing clean linens to possible contamination. The clean utility room had cardboard coverings on shelves with clean hygiene products, and a cloth chair was improperly stored between the shower and commode in a private bathroom. Additionally, cleaning and personal hygiene products were commingled in a floor cabinet in the Hillcrest South spa, and the Hillcrest South linen closet also had dust and debris under the bottom rack. Oxygen tubing was stored under a wastewater line, and hygiene products in the beauty shop were similarly stored under a wastewater line. The laundry room had linen carts that were ripped, tattered, and not easily cleanable, with one cart having a plywood false bottom that was not smooth or cleanable. The facility's policy on routine and transmission-based cleaning and disinfecting was not followed, as evidenced by these observations. During an observation, a resident in the memory care unit was seen using shared colored pencils that were not cleaned after falling on a soiled floor. The activity assistant reported that there was no set schedule for cleaning activity supplies, and items were cleaned on demand unless someone was sick. The infection preventionist and activity director confirmed that there was no cleaning schedule for shared activity supplies, and the supplies were accessible to multiple residents. The activity director acknowledged the need for a cleaning schedule and reported that some supplies had not been cleaned for several weeks. Observations of the day room revealed soiled sensory stimulation items, including a toggle switch board and a tackle box with simulated fishing supplies. The housekeeper reported that she cleaned the day room and activity supplies, but the expectation was that staff distributing the supplies would clean them after use. The director of nursing confirmed that the soiled items should have been cleaned after each use to maintain sanitary conditions and reduce the potential for cross-contamination.
Failure to Develop Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, resulting in the potential for unmet care needs. The resident, who had diagnoses including hemiplegia and hemiparesis following a stroke, was observed in the dining room leaning to one side and not initiating eating. A CNA assisting the resident was unsure of the required assistance, and the resident's electronic medical record revealed no baseline care plan. Interviews with staff indicated that the baseline care plan should have been started at admission, but it was not completed due to the responsible nurse's absence. Further observations revealed conflicting information about the resident's transfer status on a care guide taped inside the closet door. Staff members were unsure of the correct transfer method, relying on different indicators such as a blue card pinned to a cork board. Interviews with the DON and other nursing staff confirmed that the baseline care plan was not completed because the responsible nurse was absent, and there was confusion about who was responsible for completing it in her absence. The facility's policy stated that a baseline care plan should be developed within 48 hours of admission, but this was not adhered to in this case.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for two residents, resulting in potential harm to their physical, mental, and psychosocial well-being. Resident R9, who was at risk for pressure ulcers and had a history of pressure injuries, was observed with shearing on his right buttock. Despite the presence of a wound, there was no person-centered treatment plan for the shearing, and the care plan did not reflect the current condition. The staff, including the CNA and RN, were aware of the shearing but did not update the care plan accordingly. The MDS Coordinator, responsible for care plans, did not create a care plan for the shearing due to her absence, and there was no system in place for other staff to update care plans in her absence. Resident R11, diagnosed with PTSD and other mental health disorders, reported being triggered by another resident. Despite multiple staff members being aware of the triggers and the resident's fixation on another peer, there was no care plan addressing the PTSD diagnosis or the specific triggers. The social worker, responsible for mood and behavior-related care plans, acknowledged the need for a care plan but had not created one. The lack of a care plan for PTSD and triggers left the resident without a structured approach to manage her condition and interactions with the triggering peer. The deficiencies in care planning for both residents highlight a systemic issue in the facility's approach to developing and updating person-centered care plans. The absence of comprehensive care plans for identified issues, such as skin shearing and PTSD triggers, indicates a failure to ensure that residents' needs are consistently and adequately addressed. This lack of proper care planning could potentially compromise the residents' well-being and quality of care provided by the facility.
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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.
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Nursing homes near Allegan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ely Manor | 1.3 mi | ★★★★★ | 34 | 0 |
| Alamo Nursing Home Inc | 12.6 mi | ★★★★★ | 11 | 0 |
| Life Care Center Of Plainwell | 12.8 mi | ★★★★★ | 20 | 0 |
| The Laurels Of Sandy Creek | 15.4 mi | ★★★★★ | 6 | 1 |
| Plainwell Pines Nursing And Rehabilitation Communi | 18.3 mi | ★★★★★ | 12 | 1 |
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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 July 2026) and official state health department websites.