Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Calhoun County Medical Care Facility during CMS and state inspections, most recent first.
Food service areas had multiple sanitation and maintenance deficiencies. Surveyors observed a dirty ice scoop holder, debris on a tabletop mixer, buildup on a water dispenser spout, crumbs and staining inside clean utensil drawers, and holes in cabinetry near plumbing access points. In addition, the ice machine air gap in more than one kitchen had fallen below the drain overflow rim, and the DM stated some items should be cleaned weekly while maintenance would address the plumbing issues.
Water Management Program Not Fully Implemented: The facility failed to maintain an active and ongoing plan to reduce the risk of Legionella and other OPPP. The FOM stated that only soiled utility room water lines were flushed, no other fixtures were identified for routine flushing, and no water sampling for disinfection or Legionella was being performed. Observation found an unused spa room with the tub disconnected, the shower fixture removed, and no flushing schedule in place, while another spa tub room was being used for storage and had fixtures that were not accessible for easy flushing.
A resident with dementia and moderate cognitive impairment was found with fresh bruising on both hands and a bleeding skin tear after hands-on care by two CNAs. She repeatedly yelled that the staff were hurting her, asked them to stop and leave her alone, and stated that “those girls” had beaten her up. Staff observed the resident in distress, noted the injuries, and the facility substantiated abuse by both CNAs.
The facility failed to maintain food safety and sanitation standards, with improperly stored scoops, unlabeled containers, and a lack of air gaps in plumbing. Germicidal wipes not approved for food contact were found, and sanitizer testing was inadequate. Equipment and ice dispensers were observed with food debris and buildup, and various areas had accumulated debris, indicating systemic cleanliness issues.
The facility lacked an effective infection prevention and control program for Legionella and OPPP, as evidenced by the absence of routine water testing and oversight of the Water Management Program. Discolored water and stagnant lines were observed in several areas, and the facility's policy on system flushing and disinfection monitoring was not adhered to.
The facility failed to properly store and label medications, as observed in three medication carts and a medication room. An RN and LPN found opened and undated eye drops in the medication carts, and expired medications were found in an unlocked cupboard in the medication room. The facility's policy requires medications to be dated when opened and discarded according to guidelines.
A facility failed to perform a significant change MDS assessment for a resident who transitioned to supportive care and was identified with a terminal illness. Despite a decrease in responsiveness and a shift to comfort care, the last assessment was outdated, and staff interviews confirmed the oversight.
The facility failed to provide appropriate care to three residents, leading to potential unmet care needs. A resident on Supportive Care continued to receive routine tests and weighing against family consent. Another resident with a history of eye inflammation had no documented treatment despite visible symptoms. A third resident on insulin did not have her blood sugar levels monitored as required. Inadequate staff training on Supportive and End of Life Care was also noted.
The facility failed to properly store, clean, and label respiratory equipment for two residents, increasing the risk of cross-contamination and respiratory illnesses. One resident had oxygen tubing dated 11 days prior and un-bagged nebulizer equipment, while another had a BiPAP mask resting directly on the bed. Staff did not rinse or clean the CPAP/BiPAP masks, and there were no orders for cleaning the equipment. The DON expected equipment to be stored in black bags and cleaned weekly, but this was not done.
A resident received medications intended for another resident due to a miscommunication among nursing staff. The resident, who was cognitively intact and had significant health conditions, reported feeling 'fuzzy' after receiving the wrong medications, including Percocet, Atorvastatin, and Gabapentin. The error occurred when an LPN trainee misunderstood instructions and administered the medications to the wrong resident. The incident was documented, but there was a lack of follow-up monitoring and education for the staff involved.
Food Service Area Sanitation and Plumbing Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area after multiple observations showed food-contact and nonfood-contact surfaces with visible soil and debris. On 4/22/26, surveyors observed the main ice scoop holder with white and brown crusted debris on the bottom, the underside of a tabletop mixer with white accumulation in the crevices of the under arm, yellow accumulation on the underside spout of a water dispenser in the drink station area, and crumbs and debris inside clean utensil drawers in the Red Oak kitchen, the [NAME] Ridge kitchen, and the Beechwood and Maple upstairs kitchens. The metal spoon drawer in the [NAME] Ridge kitchen also had yellow sticky staining on the bottom, and the undercounter cabinetry in the upstairs kitchens had holes behind and near plumbing access points where pests could enter. Surveyors also observed plumbing and drainage concerns in multiple kitchen areas. In the [NAME] Court kitchen and the Red Oak kitchen, the air gap for the ice machine drain had fallen below the overflow rim of the drain and was no longer creating a physical gap between the plumbing. The report cited these findings under the 2022 FDA Food Code sections addressing clean equipment and utensils, backflow prevention, and cleaning frequency for physical facilities. The Dietary Manager stated that the scoop holder should be cleaned weekly, that the old scoop had rough edges and would be replaced, and that maintenance would take care of the plumbing issues.
Water Management Program Not Fully Implemented
Penalty
Summary
The facility failed to have an active and ongoing infection prevention and control plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During interview, the Facilities Operations Manager stated that housekeeping staff flush the domestic water lines in soiled utility rooms that are not used regularly, but there were no other rooms or fixtures identified for regular flushing. The Facilities Operations Manager also stated that the facility was not performing any sampling of the water for disinfection or legionella. Observation of the [NAME] Ridge spa room found the spa tub disconnected from the water supply and moved to the far side of the spa, and the shower fixture had been removed, indicating it was not used regularly. Maintenance staff stated that the water lines run through the ceiling in this area, and the Facilities Operations Manager stated that staff and residents do not use this spa for showering and bathing residents and instead take residents of that hall to another spa. When asked if these fixtures were on a flushing schedule, the Facilities Operations Manager stated no. Observation of the Red Oak spa tub room found the room being used for storage of boxes and supplies, with the commode and sink portion not accessible for use or easy flushing of the water fixtures. The spa tub had been disconnected from the water supply, and the Facilities Operations Manager stated it had been disconnected for a while. Review of the facility's Water Management Program - Legionella, last revised on 4/15/2026, stated that the purpose of the plan was to provide guidance on recognition, evaluation, and control of Legionella and to verify and validate that control measures are effective, and included statements to eliminate dead legs, avoid stagnation, and check residual chlorine to ensure proper disinfection is available.
Abuse During Hands-On Care
Penalty
Summary
The facility failed to protect a resident with cognitive impairment from mental and physical abuse by staff during hands-on care. The resident had diagnoses including cognitive communication deficit, dementia, muscle weakness, and need for assistance with personal care. Her MDS showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment, and she was receiving scheduled pain medication but did not routinely have pain. On 11/7/2025, the resident was found with new dark discoloration and bruising on both hands, including a bleeding skin tear on the back of the left hand. She was distressed, agitated, and repeatedly stated that “two girls” had beaten her up, that they were hurting her, and that they had grabbed and twisted her arms. The incident report and progress notes documented pain, emotional distress, and the resident’s repeated requests for staff to stop and to leave her alone. A physician order was entered to observe the bruising and skin tear and document findings each shift. The investigation and staff statements showed that CNA D was assisting the resident with dressing and CNA L later assisted with repositioning and incontinence care while the resident was yelling that she was being hurt and asking them to stop. CNA L stated she continued care because the resident was wet and needed a brief change, even after the resident asked her to leave and stop touching her. Multiple staff members observed the bruising and skin tear, and the resident’s DPOA confirmed the injuries were not present the prior evening. The facility substantiated abuse against CNA L and CNA D and determined their actions caused or contributed to the resident’s emotional distress and physical injuries.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen evaluation. Clear plastic scoops were improperly stored on the outside of bulk storage containers, with two scoops showing discolored surfaces. Additionally, the containers were not labeled with the common names of their contents. The facility's Certified Dietary Manager (CDM) confirmed the improper storage practice. Furthermore, the two-compartment preparation sink was directly connected to the wastewater line without an air gap, posing a risk of cross-contamination. The overhead dish spray and sink sprayer in the Beachwood kitchenette were also improperly positioned, creating potential cross-connections between potable water and wastewater. The facility was found to be using germicidal wipes not approved for food contact surfaces, and an open bottle of Spic and Span was observed without a cap in the janitor's closet. The facility did not regularly test their sanitizer buckets, and the available test strips were expired and not suitable for the type of sanitizer used. Additionally, the large floor mixer and meat slicer were observed with dried food debris, indicating inadequate cleaning practices. The ice dispensers in multiple satellite kitchens had a buildup of an orange substance inside the dispensing shoots, further highlighting the facility's failure to maintain cleanliness. The facility also exhibited an accumulation of debris in various areas, including under the racks of the walk-in cooler floor, structural portions of the ventilation hood, and behind the oven in the Red Oak kitchenette. The CDM acknowledged the need for cleaning these areas. These observations indicate a systemic issue with maintaining cleanliness and adhering to food safety standards, potentially leading to foodborne illnesses among residents consuming food from the facility's kitchen.
Inadequate Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program specifically targeting the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). During an interview, the Facilities Operations Manager (FOM) was unable to confirm the existence of a team overseeing the Water Management Program (WMP) or any established control limits to mitigate the risk of Legionella and OPPP. The FOM, being relatively new to the position, had limited involvement with the WMP, indicating a lack of proper orientation or training in this critical area. Observations during a facility tour revealed several water fixtures with potential risks for developing OPPP/Legionella. Discolored water was noted in multiple locations, including the [NAME] Ridge soiled utility room and the Maple soiled utility room, where brown water ran from faucets before clearing. Additionally, a janitor's closet had a cold-water line shut off, leading to a sewer gas odor, and a commercial humidifier was left on despite not being in use. The facility's policy on water management, which includes system flushing and monitoring disinfection levels, was not being followed, and no completed CDC Legionella tool-kit was observed as part of the WMP.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed in three medication carts and one medication room. During an observation, a Registered Nurse (RN) found three opened and undated eye drops in the Maple Grove Medication cart. The RN confirmed that these medications should have been dated when opened, but noted that some staff document the open date in a binder on the medication cart, which was not done in this case. Similarly, a Licensed Practical Nurse (LPN) found an open and undated eye drop in the [NAME] Court Medication cart and was unsure of when it had been opened. Further observations revealed additional issues in the Red Oak Trail Medication cart and medication room. An LPN found two opened and undated eye drops in the medication cart and expired medications in an unlocked cupboard in the medication room. These expired medications included a tube of triple antibiotic ointment, a tube of triamcinolone ointment, and a bottle of carbamide peroxide ear drops, all past their manufacturer's expiration dates. The facility's policy requires that all drugs have an expiration date on the manufacturer's container and that specific medications with shortened expiration dates be dated when opened and discarded according to pharmaceutical guidelines.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to perform a Minimum Data Set (MDS) significant change in condition assessment for a resident, resulting in the potential for unmet care needs. The resident was admitted to the facility and later had a Supportive Care Goals Worksheet completed, indicating a do not resuscitate (DNR) order and other limitations on medical interventions. The resident's authorized decision maker and medical professionals signed the form, consenting to supportive care focused on quality of life and comfort. Subsequently, the resident was determined to have a terminal illness with a life expectancy of less than six months. Despite these significant changes in the resident's condition, including a decrease in responsiveness and transition to comfort care, the facility did not complete a significant change MDS assessment. The last such assessment was conducted months prior, in October 2024, and did not reflect the resident's current prognosis or care plan. Interviews with facility staff, including the MDS nurse and Director of Nursing, confirmed the oversight, as the resident's transition to supportive care and identification of a terminal illness were not followed by the required assessment.
Failure to Provide Appropriate Care and Services to Residents
Penalty
Summary
The facility failed to provide appropriate care and services to three residents, resulting in potential unmet care needs. Resident #87 was placed on Supportive Care, with family consent to discontinue measures such as routine testing and weighing. However, the facility continued to perform laboratory tests and weigh the resident, contrary to the Supportive Care Goals Worksheet. Additionally, the educational training provided to staff on Supportive and End of Life Care was inadequate, lacking current standards of practice and failing to specify the increased care needs for residents receiving these services. Resident #26, who had a history of blepharoconjunctivitis, was observed with a red and swollen left lower eyelid, yet no change of condition assessment or clinical documentation was made. The Licensed Practical Nurse acknowledged the condition but did not notify the physician or document any orders for treatment. The Director of Nursing confirmed the lack of documentation and could not explain why the condition change had not been addressed, despite the nurse's awareness of the issue. Resident #57, who was on long-acting insulin, did not have her blood sugar levels monitored as per physician orders. The resident reported that staff were not monitoring her blood sugars, and a review of her medical records confirmed the absence of blood sugar monitoring from 1/31/25 to 2/18/25. The Director of Nursing identified a transcription error and acknowledged that the resident should have had a physician order for blood sugar monitoring, which was not followed by the staff.
Improper Storage and Cleaning of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage, cleaning, and labeling of oxygen and respiratory equipment for two residents, resulting in the likelihood of cross-contamination and respiratory illnesses. Resident #57, a cognitively intact [AGE] year old female with a history of acute and chronic respiratory failure, congestive heart failure, and other conditions, was observed with oxygen tubing dated 11 days prior and nebulizer equipment that was un-bagged and undated. The resident reported that staff did not rinse or clean her CPAP mask, which she used nightly, although she had done so daily before her admission to the facility. Licensed Practical Nurse (LPN) H confirmed that oxygen tubing was changed weekly, and CPAP equipment was stored in black cloth bags and changed monthly, but there were no orders for cleaning the CPAP/BiPAP equipment for Resident #57. Resident #61, also cognitively intact, was observed with BiPAP equipment in her room, with the mask resting directly on the bed. The resident reported that staff filled the water chamber and connected the oxygen but did not rinse the mask. LPN H verified that Resident #61's respiratory mask was laying directly on the bed and that there was no black bag available for storage. The Director of Nursing (DON) B stated that CPAP/BiPAP equipment should be stored in black bags and cleaned weekly, and that oxygen tubing should be changed weekly, but this was not being done for Residents #57 and #61.
Medication Error Due to Miscommunication Among Nursing Staff
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving a resident who was administered medications intended for another resident. The resident, a cognitively intact female with a history of acute and chronic respiratory failure, congestive heart failure, and other significant health conditions, reported feeling 'fuzzy' the day after the error. The error occurred when a male nurse administered medications, including Percocet, Atorvastatin, and Gabapentin, which were not prescribed to the resident. The nurse later apologized and informed the resident that the Nurse Practitioner had been notified. The incident was documented in the resident's progress notes, and vital signs were recorded, showing no immediate adverse effects. However, the resident was given a controlled narcotic, Percocet, in error, and subsequently received another controlled narcotic, a cough syrup with codeine, five hours later. The facility's records indicated that the medications were intended for another resident with a similar name, and the error was attributed to a misunderstanding between the nurses involved. Interviews with the staff involved revealed that the Licensed Practical Nurse (LPN) trainee, who had been working at the facility for three weeks, was instructed by a day nurse to deliver the prepared medications. The trainee misunderstood the instructions and administered the medications to the wrong resident. The preceptor, who was also new and had not been trained to be a preceptor, was not present at the time of the error. The Director of Nursing and other staff were notified of the incident, but there was a lack of documentation regarding the monitoring of the resident after the error, and the staff involved had not received education related to the incident at the time of the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 235 citations issued within 25 miles in the last 12 months — including the 1 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Battle Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinnacle Care Of Battle Creek | 1.8 mi | ★★★★★ | 15 | 0 |
| The Oaks At Battle Creek | 3.6 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Battle Creek | 3.7 mi | ★★★★★ | 12 | 0 |
| The Laurels Of Bedford | 6 mi | ★★★★★ | 14 | 0 |
| Evergreen Manor Senior Care Center | 7.1 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Calhoun County Medical Care Facility.
100% money-back within 48 hours.
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.