Above 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 Fisher Senior Care And Rehabilitation during CMS and state inspections, most recent first.
Advance directives and code status were not updated or explained clearly. A resident with Anxiety, Intellectual Disabilities, and Dementia had a DNR order and care plan, but care conference notes over several months stated she wished to remain CPR without those wishes being reflected in the order set or care plans. The SW later acknowledged the resident may not have understood the CPR vs DNR discussion, and when the terms were explained in clear language, the resident stated she wanted to go peacefully and not have chest compressions.
Oxygen Not Administered as Ordered: A resident with respiratory failure, COPD, emphysema, pulmonary HTN, and O2 dependence was observed receiving O2 via NC at 6 L/min when the order was for 5 L continuously. Staff also noted no humidification bottle was attached, and an RN stated humidification was usually added only if the resident complained of dryness.
Unnecessary psychotropic medication use and missing clinical rationale: two residents were prescribed duplicate antidepressant therapy without documentation supporting the combined regimen, and one resident received olanzapine for MDD without an appropriate documented indication. Record review and staff interview showed no charted risk-versus-benefit rationale or supporting MH documentation for the psychotropic use.
Improper Insulin Pen Administration Site: An LPN administered Insulin Glargine to a resident with DM, HF, and COPD by injecting 10 units into the upper arm near the deltoid rather than into an area with adequate fatty tissue. The resident required ADL assistance and had intact cognition. Surveyor observation and record review showed the injection site was not consistent with the Lantus Solostar instructions, which specify use of the outer back area of the upper arm where there is fatty tissue.
Failure to use PPE during enteral feeding occurred when a nurse provided PEG tube feeding to a resident on enhanced barrier precautions without wearing a protective gown. The resident had a feeding tube, stroke, and hypotension, required total ADL assistance, and the facility’s policy called for gown and gloves during high-contact care such as feeding tube use. PPE was available at the doorway, and the ADON confirmed the gown should have been worn.
The facility failed to ensure a clean and homelike environment, as observed with unlabeled personal items and improper storage practices. A resident's TED hose lacked identification and documentation, while another resident's denture cup was stored under a towel dispenser. Additionally, a partially used juice bottle was left unrefrigerated. Two residents shared a room with unlabeled urinals, increasing the risk of cross-contamination.
A facility experienced a medication error rate of 7.69% due to an LPN failing to prime insulin pens before administration to three residents. The Director of Nursing acknowledged the policy's lack of specific instructions on priming, and the LPN was unaware of the requirement, leading to incorrect insulin dosages.
The facility failed to update care plans for two residents, leading to potential unmet needs. One resident experienced significant weight loss not reflected in their care plan, and their catheter care plan was outdated. Another resident's advance directive care plan did not match their DNR status. Staff responsible for updates acknowledged the discrepancies.
A resident with a history of cataracts and diabetes did not receive necessary vision care follow-up due to missed appointments and lack of documentation. The facility failed to implement the optometrist's recommendations for eye drops, and staff were unable to account for the resident's absence during a scheduled eye care visit. The Director of Nursing acknowledged the oversight, and the facility did not provide a vision care policy upon request.
A facility failed to conduct a scheduled 72-hour care conference for a resident with multiple diagnoses, including pneumonia and chronic kidney disease. The resident, who was cognitively intact, and their family were not informed about the conference, which was intended to discuss care plans and needs. The social worker could not explain why the conference was not held, and no record of the meeting was found in the electronic medical record.
Advance directives and code status were not updated or explained clearly
Penalty
Summary
The facility failed to ensure that advance directives were updated in a timely manner and explained in clear language for one resident who was admitted with diagnoses including Anxiety, Intellectual Disabilities, and Dementia. The record showed a DNR physician order and a code status form signed by the resident, physicians, and witnesses stating that no resuscitation should be attempted if her heart and breathing stopped. The care plan also documented that advance directives had been discussed and that the resident was DNR, with the resident identified as her own decision maker. Care conference documentation over a nine-month period stated that the resident wished to remain CPR, but those stated wishes were not reflected in the order set or care plans. During interview, the Social Worker stated she did not recall whether anyone was alerted after the code status changed and acknowledged she could not update orders. When asked whether the resident fully understood the difference between CPR and DNR given her intellectual disability and recent cognitive decline, the Social Worker stated it was plausible the information had not been explained clearly enough. When the Social Worker asked the resident what CPR meant, the resident asked for an explanation and then said yes to chest compressions, indicating she did not fully comprehend the discussion. After the Social Worker later explained CPR versus DNR in totality and in clear language, the resident stated she would not want chest compressions and wanted to go peacefully, and the Social Worker stated the resident would remain DNR.
Oxygen Not Administered as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered for Resident #43, who had diagnoses including respiratory failure, primary pulmonary hypertension, emphysema, COPD, dependence on supplemental oxygen, and heart failure. The resident’s MDS showed full cognitive ability with a BIMS score of 15/15 and that she needed some assistance with care. The physician order in the record directed oxygen at 5 L via nasal cannula continuously, and the care plan also directed oxygen at 5 L via nasal cannula as ordered. During observation, the resident was seen in her room with a nasal cannula connected to an oxygen concentrator set at 6 L/minute, which did not match the ordered 5 L/minute. On one observation, there was no humidification bottle attached, and when asked about humidification, the nurse stated they usually waited to add it unless the resident complained of dryness. A later observation again showed the concentrator set at 6 L/minute, and the nurse confirmed the physician order read 5 L/minute via nasal cannula.
Unnecessary Psychotropic Medication Use and Missing Clinical Rationale
Penalty
Summary
The facility failed to provide a clinical rationale for duplicate antidepressant therapy for two residents and failed to ensure an accurate indication for an antipsychotic medication for one resident. Resident #4 was readmitted with diagnoses including metabolic encephalopathy, atrial fibrillation, major depressive disorder, and mood disorder, and her medication record showed Mirtazapine 45 mg for major depressive disorder started on 9/13/2025 and Zoloft 2.5 mg for major depressive disorder ordered on 3/24/2026. Review of nursing, physician, and psychiatric progress notes found no documentation supporting the use of dual antidepressant therapy, and Social Worker D stated she could not locate a risk-versus-benefit rationale in the chart. Resident #37 was admitted with diagnoses including Alzheimer’s, anxiety, chronic kidney disease, major depressive disorder, and insomnia, and her orders included Trazodone HCl 100 mg for major depressive disorder started on 9/12/2025 and Venlafaxine HCl ER 150 mg for major depressive disorder started on 3/24/2026. Review of the record found no documentation supporting the dual antidepressant regimen, and Social Worker D confirmed there was no supporting documentation in the chart. Resident #43 was admitted with acute respiratory failure, major depressive disorder, and pulmonary hypertension, and her orders included Olanzapine for major depressive disorder. The record and care plan referenced antidepressant and antipsychotic medication use for mood alteration, but there was no supporting documentation for the indication; Social Worker D stated the resident had been admitted on Zyprexa and other psychotropics through community mental health, but no mental health documentation had been requested, and she acknowledged major depressive disorder was not an appropriate indication for olanzapine.
Improper Insulin Pen Administration Site
Penalty
Summary
The facility failed to administer insulin per professional standards for Resident #43, resulting in inaccurate site administration with the likelihood of malabsorption of insulin. During medication administration on 4/14/2026 at 8:26 AM, Nurse K gathered the resident’s morning medications, including an Insulin Glargine (Lantus) pen, prepared the pen, entered the resident’s room, and injected 10 units into the resident’s right arm approximately 1 1/2 inches below the center of the deltoid muscle. Later that morning, Nurse K approached the surveyor and asked if something had been done wrong, and when asked about the injection site, stated that the needle was so small. Record review showed Resident #43 was admitted with diagnoses including Diabetes Mellitus, heart failure, and Chronic Obstructive Pulmonary Disease, required assistance with ADLs, and had intact cognition. The physician order directed Insulin Glargine 10 units subcutaneously. A later review of the Lantus Solostar pen instructions stated that only the outer back area of the upper arm where there is fatty tissue should be used, indicating the observed injection site was not consistent with the documented administration guidance.
Failure to Use PPE During Enteral Feeding
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure PPE was worn during high-contact care for a resident on enhanced barrier precautions for MDRO prevention. The resident had an admission diagnosis history that included a feeding tube, stroke, and hypotension, required assistance with all ADLs, and had intact cognition. The resident’s Kardex directed INFECTION enhanced barrier precautions, including gown and gloves for high-contact resident care activities. During observation, a nurse was seen at the bedside administering enteral feeding via the PEG tube while standing close to the bed, with knees touching the bed sheet, and the nurse was not wearing a protective gown. PPE supplies were available in a caddy near the doorway, and an enhanced barrier precautions sign was posted on the door. When asked, the ADON stated the nurse should have been wearing a protective gown during enteral feeding. The facility policy reviewed by surveyors stated that gown and gloves are to be used during high-contact resident care activities, including feeding tube care or use.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, leading to potential health risks. Resident #28 had a pair of TED hose in a shared bathroom without any identification, and there was no order or care plan for their use. The Director of Nursing confirmed the lack of documentation and identification for the TED hose. Resident #37 had a denture cup placed under a towel dispenser, risking contamination from water drips. Additionally, a partially used bottle of cranberry juice was found at the bedside without a date of opening or refrigeration, contrary to facility policy as confirmed by the Culinary Specialist. Residents #100 and #101 shared a room where personal items like urinals were not labeled with resident identification, posing a risk of cross-contamination. The Infection Control Preventionist acknowledged the lack of labeling and improper storage of personal items, such as the denture cup under the towel dispenser. These observations highlight the facility's failure to ensure personal items are properly labeled and stored, increasing the potential for infection and foodborne illness among residents.
Medication Administration Errors Due to Lack of Insulin Pen Priming
Penalty
Summary
The facility failed to ensure accurate medication administration, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was identified during the observation of medication administration for three residents. The Licensed Practical Nurse (LPN) 'C' was observed administering medications to these residents without priming the insulin pens as required. Specifically, LPN 'C' administered insulin to residents R25, R4, and R14 without priming the insulin pens, which is a necessary step to ensure the correct dosage is delivered. During interviews, the Director of Nursing (DON) acknowledged that the facility's policy does not specify the amount of insulin to prime, but stated that the manufacturer's recommendation is typically followed, which involves priming with 2 units. LPN 'C' admitted to being unaware of the need to prime the insulin pens and mentioned that they were informed by other staff members about the priming requirement. The facility's policy on injectable medication administration, revised in January 2018, was reviewed and found to lack specific instructions on priming insulin pens, contributing to the medication administration errors observed.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise care plans for two residents, resulting in missing updates and potential unmet needs. Resident #19, who has severe cognitive impairment, experienced significant weight loss of 25.8 pounds (18%) over 30 days, which was not reflected in the nutrition care plan until much later. The Certified Dietary Manager acknowledged responsibility for updating the care plan but could not explain the delay. Additionally, the care plan for Resident #19's indwelling catheter was outdated, listing incorrect catheter specifications, which was confirmed by the Director of Nursing. Resident #39, also with severe cognitive impairment, had a discrepancy between their advance directive care plan and the physician's order for a do not resuscitate (DNR) status. The care plan incorrectly indicated that the resident was a full code, despite signed DNR documents. The social worker responsible for updating the care plan confirmed the mismatch between the care plan and the physician's order. The facility's policy requires ongoing assessments and timely revisions of care plans as residents' conditions change, which was not adhered to in these cases.
Failure to Provide Vision Care Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received necessary vision services and follow-up care, resulting in untreated or unidentified vision issues. The resident, who had a history of cataracts, diabetes, and dry eyes, expressed concerns about his deteriorating vision and the need to see an eye doctor. Despite recommendations from an optometrist for regular follow-ups and specific eye care treatments, the facility did not document or implement these recommendations effectively. The resident's medical records indicated a missed eye care appointment due to the resident being unavailable, with no documentation explaining the absence. Additionally, the resident was not seen during a subsequent visit by the eye care group, and there was no clear reason provided for this oversight. The facility's staff, including the social worker designee and scheduler, were unable to account for the resident's whereabouts during the missed appointment and did not ensure the resident was available for the next scheduled visit. Furthermore, the facility did not follow through with the optometrist's recommendations for artificial tears, as there were no orders for the eye drops in the resident's medical records. The Director of Nursing acknowledged the lack of documentation and follow-up on the optometrist's recommendations, indicating a systemic issue in ensuring residents receive necessary vision care. The facility also failed to provide a policy for vision care upon request, highlighting a gap in their procedural documentation.
Missed 72-Hour Care Conference for Resident
Penalty
Summary
The facility failed to conduct a scheduled 72-hour care conference for a resident, resulting in a lack of communication and information for both the resident and their family. The resident, who was cognitively intact with a BIMS score of 15, was admitted with diagnoses including pneumonia, atrial fibrillation, chronic kidney disease, and a malignant neoplasm of the bladder. The care conference was intended to discuss the admission process, medications, dietary needs, activities, therapy plans, and home care needs. However, the conference was not held as planned, and the family, who was prepared to join by phone, was not contacted by the facility. Interviews with the social worker revealed that the care conference was scheduled for the day the resident passed away, but there was no explanation provided for why it was not conducted. The facility's policy requires the social services director or designee to contact the resident's family and maintain records of such notices, including the date, time, and method of contact. A review of the care conference calendar confirmed the scheduled meeting, but no record of the conference being completed was found in the electronic medical record.
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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 Mayville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tuscola County Medical Care Facility | 11.1 mi | ★★★★★ | 11 | 0 |
| Marlette Community Hospital Ltcu | 14.4 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Frankenmuth | 18.9 mi | ★★★★★ | 5 | 0 |
| Wellspring Lutheran Services | 19.1 mi | ★★★★★ | 17 | 0 |
| Lapeer County Medical Care Facility | 19.5 mi | ★★★★★ | 15 | 0 |
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