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 Eaton County Medical Care Facility during CMS and state inspections, most recent first.
Food service equipment was not effectively cleaned and maintained, affecting 118 residents. Surveyors observed a walk-in freezer with damaged air curtain strips, a worn door gasket, and severe frost buildup on the ceiling near the refrigeration fan, along with a microwave oven interior that was yellowed, etched, and particulate, 3 of 6 non-functional hood light assemblies, and a damaged Formica surface adjacent to a sink in the Unit A kitchenette. Facility policy required freezers to be kept free of excessive frost and dietary staff to report faulty equipment.
Failure to provide meaningful resident activities: Residents with dementia, blindness, mobility limits, and intact cognition were observed sitting idle in halls and common areas with little engagement, while unit calendars listed only a few activities or staff visits. A resident with dementia on a secured unit was repeatedly seen asleep or staring blankly with no staff attempts to engage him, a legally blind resident reported he could no longer participate in Bingo without help and had no assistance with books on tape, and other residents stated they were locked down, had limited activities, and were just sitting and staring at each other. Records showed minimal or no group participation and incomplete documentation of one-on-one or independent activities.
A resident admitted with acute respiratory failure had an MDS coded as having received an anticoagulant in the prior 7 days, but the MAR and physician orders showed no anticoagulant was prescribed or administered. The RN/MDS Coordinator reviewed the MDS, MAR, and orders and agreed there was no documentation to support the coding.
The facility failed to maintain food safety standards, with food stored on the floor, inadequate cleaning of equipment, and improper backflow prevention. Ice machines and utensils were found with debris, and temperature control requirements were not met, posing a risk of foodborne illness.
The facility failed to maintain an effective Water Management Plan, leading to stagnant water in several fixtures and brown water discharge. Maintenance staff were unsure about control measures, and the facility lacked a comprehensive risk assessment, increasing the risk of waterborne pathogens.
The facility's medication error rate was 14.29%, exceeding the acceptable threshold due to multiple errors. A resident mixed Miralax with oatmeal instead of liquid, another received only part of a prescribed combination medication, and a third had a delayed-release capsule improperly administered. Additionally, a resident was nearly given the wrong form of Calcium, and there was a timing error with Gabapentin administration. Staff interviews revealed a lack of adherence to medication protocols.
The facility failed to manage medications properly, with expired medications found in carts and improper storage in a medication refrigerator. Additionally, a resident with severe cognitive impairment was found with unidentified pills at her bedside, contrary to facility policy requiring nurse observation during medication administration.
A facility failed to ensure a complete DNR order for a resident, as it was missing a required second witness signature. The Michigan Do-Not-Resuscitate Procedure Act requires two witness signatures, but the document only had one. Staff interviews confirmed the oversight, which could lead to the resident's medical care preferences not being honored.
A resident with multiple diagnoses, including paraplegia and vascular dementia, was found to have a left humerus fracture incidentally during an X-ray. The facility failed to promptly investigate or report the injury, as required by federal regulations. Staff interviews revealed a lack of consensus on the need for reporting, attributing the injury to a possible pathological cause without further investigation.
A resident with multiple diagnoses was found to have a left humeral neck fracture incidentally during a chest X-ray. The facility failed to thoroughly investigate the injury, resulting in a potential deficiency in addressing possible abuse or neglect. The initial response was inadequate, with delays in compiling a complete incident report and investigation. Staff interviews revealed a lack of consensus on the need for further investigation, highlighting a deficiency in the facility's protocol for handling such incidents.
A resident's MDS assessment was inaccurately completed, marking pneumonia as an active diagnosis despite the resident's denial and lack of supporting documentation. The error was confirmed by the MDS Nurse, who acknowledged the incorrect submission to CMS, which was later corrected.
A facility failed to monitor a resident's anticoagulant medication properly. The resident, with atrial fibrillation, had orders for Coumadin and required regular PT/INR tests. Despite orders for specific test dates, the tests were not completed due to incorrect entry as therapy orders instead of nursing orders, leading to a lapse in medication monitoring.
The facility failed to address 26 resident grievances over six months, leading to unresolved issues and decreased quality of life. Concerns included noise, staff behavior, dietary requests, and missing items. Resident council meetings were split due to overcrowding, and some residents were uncomfortable speaking due to recordings without consent. The grievance process was inadequately managed, with incomplete forms and no follow-up, as admitted by the Nursing Home Administrator.
Food Service Equipment Not Maintained
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, affecting 118 residents. During an initial tour of the food service area with the Culinary Services Manager, the walk-in freezer was observed with cracked, brittle, and missing air curtain strips, a worn, torn, and etched entrance door gasket, and frozen water condensation droplets with severe heavy frost deposits on the ceiling adjacent to the refrigeration fan unit. The affected frost area measured approximately 8 feet by 8 feet. The Culinary Services Manager stated she would contact maintenance for repairs. In the same tour, the [NAME] Beach microwave oven interior ceiling was observed to be yellowed, etched, and particulate, with etched, corroded, and particulate ceiling/wall junctures. The Culinary Services Manager stated she would remove the microwave and have it replaced. Also observed were 3 of 6 non-functional ventilation hood light assemblies. In the Unit A kitchenette, the Formica laminate surface adjacent to the two-compartment sink was observed to be etched, scored, porous, and particulate, with the damaged area measuring approximately 2 inches by 8 inches. Record review showed facility policies requiring freezers to be maintained free of excessive frost and ice buildup and dietary staff to report faulty or malfunctioning equipment.
Failure to Provide Meaningful Resident Activities
Penalty
Summary
The facility failed to provide impactful and meaningful activities for residents on multiple units, including residents with dementia, cognitive impairment, blindness, and mobility limitations. Resident #55, who lived on the secured dementia unit and had long- and short-term memory impairment with severe impairment in daily decision-making, was repeatedly observed sitting in common areas asleep or staring blankly while the television or radio played at low volume. Staff were observed conversing at the nurse’s station or absent from the area, and no attempts were made to engage the resident or encourage participation with peers. The posted activity calendars on the unit listed only limited staff visits or activities on unit, and the resident’s activity record showed no group participation for the last 30 days and no documentation that activities were offered and refused. Resident #104, who was legally blind and had dementia, a cognitive communication deficit, gait and mobility abnormalities, and needed assistance with personal care, reported that he did not do much since the shutdown and that he used to attend Bingo when someone helped him with numbers and markers. He stated he no longer had anyone to help him, that staff said there was not enough help to assist him one-on-one, and that his books on tape sat unused because he could not operate the player himself and no one had offered to help. His task sheet showed no group activity participation in the last 30 days, only TV watching and family visits, and one-on-one activity entries were documented without supporting detail. Resident #109, who had a stroke affecting the right non-dominant side, depression, and dementia but was cognitively intact on the most recent MDS, stated that residents were locked down on the unit and could not visit friends on other units, and that joint meetings, activities, birthday parties, and outings had been cancelled. He reported that the facility may do only one or two activities a day and that limited activity aides prevented involvement of everyone. Resident #24, who had hereditary spastic paraplegia, atrial fibrillation, polyosteoarthritis, chronic pain, and dementia, stated that without something to do residents were just sitting and staring at each other and that they might get two activities a day if lucky. Her records showed social visits and dining room attendance documented as activity, but no documentation of the specific one-on-one or independent activities listed in her care plan. Observation and interviews also showed that activity calendars on units often listed only a few activities per day, some residents were left sitting in hallways or common areas with little engagement, and the activity director could not explain why the calendars listed staff visits instead of structured activities or how all residents were being involved.
Incorrect MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to accurately complete an MDS assessment for one resident. The resident was admitted with acute respiratory failure, and the MDS dated [DATE] coded Section N0415 question 1.E as Yes for having received an anticoagulant medication within the last 7 days. However, review of the resident’s November 2025 MAR and monthly physician orders showed the resident was not prescribed or administered any anticoagulant medication. During an interview on 02/12/26 at 3:10 pm, the RN/MDS Coordinator reviewed the resident’s November MDS, MAR, and physician orders and agreed there was no documentation to support that an anticoagulant had been administered, acknowledging that the MDS was coded incorrectly.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a kitchen tour. Vegetables and potatoes were stored directly on the floor of a walk-in cooler, and multiple boxes of food products were found on the floor of a walk-in freezer. The Head Chef noted that the staff member responsible for putting away deliveries was absent. Additionally, black spotted debris was observed on the tops and side gaskets of a cooler, and crumb debris was found in utensil drawers and on mechanical scoops, indicating inadequate cleaning practices. Further deficiencies were noted in the facility's handling of equipment and food-contact surfaces. The meat slicer, used weekly, was found with dried meat debris, and ice machines in various units had heavy accumulations of crusted white debris on their spouts. The facility also failed to maintain proper backflow prevention, as several sinks were directly connected to the wastewater system without visible air gaps, posing a risk of contamination. The facility did not comply with temperature control requirements, as an open container of soy sauce was left unrefrigerated, contrary to manufacturer instructions. Ice chests in unit kitchenettes were found with ice floating in water, and one was observed to be full of water only, indicating improper storage of food in contact with water or ice. These observations highlight the facility's failure to maintain food safety standards, potentially leading to foodborne illnesses among residents.
Deficient Water Management Plan and Stagnant Water Issues
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. During a tour, it was observed that several water fixtures, including hoppers, janitor sinks, and spa tubs, were not regularly flushed, leading to stagnant water and brown water discharge when taps were turned on. Interviews with maintenance staff revealed that these fixtures were not on a regular flushing schedule, and the Building Services Director (BSD) was unsure about the control measures and limits for water testing. The facility's Water Management Plan (WMP) lacked a comprehensive risk assessment and did not follow established guidelines such as the CDC toolkit or ASHRAE guidelines. A review of facility documentation showed that the policy required housekeepers to turn on all showers and sinks as part of daily cleaning to prevent stagnant water, but this was not effectively implemented. The Quarterly Water Test log lacked specified control limits and only contained check marks without indicating actual results. The facility's failure to perform a risk assessment and establish control measures increased the potential for waterborne pathogens to exist and spread, posing a risk of respiratory infection among residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 14.29% due to five observed medication errors among four residents. One resident, who was on a fluid restriction, mixed Miralax powder into oatmeal instead of dissolving it in water or juice as per the physician's order. Another resident was administered only sennosides without the prescribed combination of Senna-Docusate Sodium. Additionally, a resident received Cymbalta after the capsule was opened and mixed with yogurt, contrary to the delayed-release instructions. Furthermore, a resident was nearly given Calcium with Vitamin D instead of the prescribed Calcium alone, and there was a discrepancy in the timing of Gabapentin administration. Interviews with staff revealed a lack of awareness and adherence to proper medication administration protocols. The Clinical Mentor was unaware of the improper administration of Miralax, and the Director of Nursing indicated that Miralax should not be mixed with food unless approved. The facility's Director of Nursing also noted that the no-crush medication list was missing, which contributed to the improper administration of Cymbalta. These observations and interviews highlight the facility's failure to ensure that medication orders were followed accurately, leading to a significant medication error rate.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly manage medications, as evidenced by the presence of expired medications in two of four medication carts and improper storage of refrigerated medications in one of three medication storage rooms. During observations, expired medications such as Benadryl and Insta Glucose were found in the medication carts, and a medication refrigerator contained unlabeled frozen food and drinks, which should not have been stored there. The staff, including an LPN and the Director of Nursing, acknowledged these issues, confirming that expired medications should be discarded and food should not be stored with medications. Additionally, the facility did not adhere to professional practices regarding medication administration for a resident with severe cognitive impairment. The resident was found with a medication cup containing six pills at her bedside, which she could not identify. The facility's policy requires that nurses observe residents taking their medications, and self-administration is only allowed with a proper assessment and physician order, neither of which were in place for this resident. The Director of Nursing confirmed that the resident did not have the necessary assessment or order for self-medication administration.
Incomplete DNR Order Due to Missing Witness Signature
Penalty
Summary
The facility failed to ensure that updated and accurate advanced directive information was in place for a resident, specifically regarding the Do-Not-Resuscitate (DNR) order. The DNR order for the resident was missing a second witness signature, which is a requirement under the Michigan Do-Not-Resuscitate Procedure Act. This act mandates that a DNR order must be signed by the declarant or their representative, the attending physician, and two witnesses, one of whom must not be a close relative or presumptive heir. The absence of the second witness signature on the DNR order indicates non-compliance with these legal requirements. Interviews with facility staff revealed that the process for completing DNR orders on admission involves the resident or their responsible party signing the document, along with two witnesses and the physician. The Admission Coordinator and the Palliative Care Clinical Mentor both confirmed that the DNR order for the resident in question was incomplete, as it lacked the necessary second witness signature. This oversight could potentially lead to the resident's preferences for medical care not being followed by the facility or other healthcare providers.
Failure to Report and Investigate Resident Injury
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act 42CFR483.12(c). This deficiency was identified during a review of the case involving a resident who was admitted with multiple diagnoses, including paraplegia and vascular dementia. The resident was found to have a fracture in the left humerus, which was discovered incidentally during an X-ray for aspiration pneumonia. Despite the severity of the injury, the facility did not conduct a timely investigation or report the incident as required. Interviews and record reviews revealed that the resident's family was not provided with adequate information regarding the cause of the fracture. The facility's records showed that the fracture was identified on 12/11/2024, but there was a delay in initiating a comprehensive investigation. The initial incident report lacked details, and it was only after repeated requests from the surveyor that a more complete investigation was presented. This investigation, however, was conducted after the annual survey had begun, indicating a lack of prompt action by the facility. Staff interviews indicated a lack of consensus on whether the injury was suspicious or required reporting. The Clinical Mentor and LNA involved did not consider the injury to be suspicious, attributing it to a possible pathological cause without further investigation. This lack of immediate and thorough investigation, along with the failure to report the incident to the state, highlights the facility's non-compliance with federal regulations regarding the reporting of potential abuse or neglect.
Failure to Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source for a resident, resulting in a potential deficiency in addressing possible abuse or neglect. The resident, who was initially admitted with multiple diagnoses including paraplegia and vascular dementia, was found to have a left humeral neck fracture incidentally during a chest X-ray for aspiration pneumonia. Despite the discovery of the fracture, there was a lack of immediate and comprehensive investigation into the cause of the injury, as noted by the family member who reported not receiving answers about the broken arm. Interviews and record reviews revealed that the facility's response to the injury was inadequate. The incident was not initially treated as suspicious, and there was a delay in compiling a complete incident report and investigation. The initial documentation was minimal, and it took several requests from the surveyor to obtain a more detailed investigation report. The investigation, which was eventually completed, lacked resident interviews and was only finalized during the annual survey, indicating a delay in the facility's response. Staff interviews highlighted a lack of consensus on whether the injury was suspicious or required further investigation. The Clinical Mentor and DON did not suspect abuse due to the absence of bruising or other signs, and the Medical Director suggested a pathological cause. However, the lack of a timely and thorough investigation into the injury of unknown origin represents a deficiency in the facility's protocol for handling such incidents, potentially leaving other similar cases unaddressed.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #20, who was admitted with multiple diagnoses including heart failure, chronic kidney disease, and end-stage renal disease, among others. The MDS assessment, with an Assessment Reference Date of September 18, 2024, incorrectly documented an active diagnosis of pneumonia. This error was identified during an observation and interview where the resident denied having pneumonia, despite a previous hospitalization for COVID-19 in January 2024. The resident's medical record showed pneumonia was added to the diagnoses on January 12, 2024, but there was no documentation indicating it was an active diagnosis in the seven days leading up to the MDS assessment date. During interviews, the MDS Nurse confirmed the error in the MDS assessment, acknowledging that the pneumonia diagnosis was incorrectly marked as active. The nurse could not provide any documentation to support the presence of pneumonia as an active diagnosis within the required timeframe. This discrepancy led to the submission of an incorrect MDS to the Centers for Medicare/Medicaid Services (CMS), which was later corrected and resubmitted.
Failure to Monitor Anticoagulant Medication
Penalty
Summary
The facility failed to adequately monitor the use of an anticoagulant medication for a resident diagnosed with atrial fibrillation. The resident was admitted with a physician's order for Coumadin, a blood thinner, and required regular PT/INR tests to monitor blood clotting times. Despite a standing order to check PT/INR every Monday and additional orders for tests on specific dates, the tests were not completed as required. The Clinical Mentor reported that the orders were incorrectly entered as therapy orders instead of nursing orders, leading to the oversight. This deficiency was identified during interviews and record reviews, revealing a lapse in the facility's medication monitoring process.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to promptly address grievances and concerns reported by residents, both during and outside of resident council meetings, over a six-month period. This resulted in unresolved issues and a decreased quality of life for the residents. During confidential resident council meetings, it was revealed that 26 grievances had not been resolved, and there was no documented follow-up on various concerns raised by the residents. These concerns included requests for presentations, noise complaints, staff behavior, dietary requests, missing personal items, and issues with meal service. The resident council meetings were split into two due to overcrowding, and some residents were uncomfortable speaking up because the meetings were recorded without their consent. The facility did not have signed consents for recording the meetings, and the resident council minutes did not reflect the two separate meetings. Additionally, the meetings were scheduled at the same time, preventing the resident council president from attending both. The facility's grievance process was inadequately managed, with incomplete forms, lack of follow-up, and no tracking of concerns. Interviews with facility staff revealed that the Social Services Director was responsible for the grievance process but was not properly educated on completing it. The Nursing Home Administrator admitted that grievances were often handed off to department managers for simple solutions, but there was no consistent documentation or resolution process. The lack of proper follow-up and documentation led to ongoing unresolved issues, as evidenced by the incomplete grievance forms and the absence of signatures indicating resolution to the residents' satisfaction.
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 241 citations issued within 25 miles in the last 12 months — 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 Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dimondale Nursing Care Center | 11.6 mi | ★★★★★ | 0 | 0 |
| Regency At Lansing West | 14 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Lansing | 14.8 mi | ★★★★★ | 12 | 0 |
| Holt Senior Care And Rehab Center | 15.7 mi | ★★★★★ | 11 | 0 |
| Aria Nursing And Rehabilitation | 16.8 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Eaton 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.