Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Ingham County Medical Care Facility during CMS and state inspections, most recent first.
The facility failed to provide palatable food and consistent dietary glassware and flatware for 131 residents. Staff reported repeated shortages of metal silverware, cups, lids, and menu items, leading to plastic utensils, improvised drinkware, and frequent substitutions or missing alternatives. A resident with CHF, DM, and other diagnoses reported bad food, repeated hot dog meals, plastic silverware several times a week, and weight loss, while meal observations showed mismatched meal tickets, unappealing textures, and trays left untouched. Food temperature checks also found some items below required hot-holding temperatures, and a test tray showed overcooked soup, dry turkey, and bland noodles.
Food service equipment and related surfaces were not properly cleaned and maintained in multiple pantry kitchen areas. Surveyors observed a heavily soiled exhaust grill, a microwave with etched and corroded interior surfaces, a soiled ice machine with encrusted mineral deposits and a dirty drip tray, a loose hand sink goose neck with moisture-damaged cabinetry, and another microwave and toaster with encrusted food residue. Dietary knives were also stored with the food contact surface facing upward in a gray caddy, and the floor beneath the ice machine was heavily soiled with dust, dirt, and debris.
A facility failed to maintain dignified, homelike dining when plastic silverware was used after metal utensils ran out, and two cognitively intact residents reported difficulty eating and feeling humiliated by the flimsy utensils. One resident spilled food on her clothing while self-feeding, and another said she was repeatedly served plastic utensils along with poor food choices and frequent menu substitutions. Staff and dietary personnel reported ongoing shortages of silverware, cups, lids, and menu items, and the grievance log showed repeated kitchen and food complaints.
Inaccurate MDS coding was found for multiple residents. One resident’s skin assessment conflicted with the charted pressure ulcer status, another resident’s wound coding did not match the hospital discharge report or wound NP assessment, a resident with stroke and dementia was coded as not using bed rails despite observed half rails on both sides, and another resident with CVA and left arm contractures was coded as having no UE ROM impairment even though therapy confirmed the impairment.
A resident with severe cognitive impairment and a right lower leg fracture was prescribed Seroquel, but the chart showed no physician order and no documented orthostatic BP monitoring despite the care plan listing it as an intervention. The DON confirmed that residents on antipsychotic meds require monthly orthostatic BP checks and that the EMR lacked this monitoring.
A resident with stroke, dementia, COPD, dysphagia, DM2, and other chronic conditions was observed in bed with bilateral half-length side rails, but the MDS coded bed rails as not used. The care plan did not include the side rails, there was no physician order for them, and the record lacked a side rail evaluation or measurements; the DON and MDS Coordinator confirmed the missing documentation.
Failure to Provide Scheduled Showers: A resident with severe cognitive impairment and dependence for showers reported not receiving showers as often as desired. The resident’s care plan called for two showers per week, but review of shower documentation showed multiple missed showers, and the DON could not explain why the showers were not completed as directed.
Failure to Provide Meaningful In-Room Activities: A cognitively intact resident with multiple mobility and medical issues was left without activities, reading materials, or a posted activity calendar in her room. She and her daughter reported staff had not included her in activities that morning, and staff described brief room check-ins and 1:1 visits, while the AD stated preferences had been reviewed with the daughter rather than directly with the resident.
A resident who was dependent for transfers and required a mechanical lift was injured during a staff-assisted bed-to-wheelchair transfer when the lift tipped and caused a right lower leg laceration that required hospital stitches. Staff accounts indicated the lift was not positioned correctly and the base was not fully widened during the transfer, despite the resident’s care plan and facility policy calling for a two-person mechanical lift transfer.
A facility failed to consistently monitor and document meal intake, supplements, and snacks for two residents with significant weight loss. One resident with severe cognitive impairment and Alzheimer’s disease had missing meal and supplement documentation, no snack documentation, and was observed wandering while others were eating without being redirected for a snack; the resident also received a pork entrée despite a documented dislike. Another resident with dementia had variable intake, was receiving a fortified smoothie and nighttime snack for weight loss, but the smoothies were observed untouched and the record lacked consistent intake documentation and evidence that the snack was provided.
A resident with severe cognitive impairment, stroke, dementia, COPD, and multiple other diagnoses was observed in bed with bilateral half side rails, but the MDS coded bed rails as not used. The record lacked a physician order, care plan entry, side rail evaluation, and measurements, and the DON and MDS Coordinator confirmed the documentation was missing or inaccurate.
Bed Rails Not Documented or Monitored: A resident with severe cognitive impairment and multiple chronic conditions was observed in bed with half-length side rails on both sides, but the MDS coded bed rails as not used. The resident’s care plan and physician orders did not include side rails, and the record lacked a side rail evaluation, measurements, and required monitoring documentation. The DON and MDS Coordinator both confirmed the documentation did not match the observed bed rails.
Failure to Report Alleged Abuse: A cognitively intact resident with CHF and CKD reported that a CNA became angry over repeated call light use and shoved a bedpan into the resident’s hip, causing pain and a large bruise. An LPN observed the resident tearful with extreme hip pain and a large edematous area, and the abuse hotline was called, but another LPN did not report the allegation to the State Agency because she believed the injury was due to positioning and said the resident was known to change her story.
Failure to thoroughly investigate alleged abuse: A cognitively intact resident reported that a CNA became angry over repeated call light use, refused to identify herself, and later shoved a bedpan hard into the resident’s hip, causing pain and a large bruise. An LPN documented the resident’s tearfulness and right hip swelling and notified the physician and abuse hotline, but the investigation file did not include an interview with the resident and the event was later attributed to a positioning issue rather than abuse.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to adhere to professional standards for food storage and preparation, with multiple expired and unlabeled items found in the kitchen and rehab cooler. Additionally, food served during meal service was not maintained at safe temperatures, violating the 2017 FDA Food Code.
A facility failed to ensure proper witnessing of a DNR document for a resident with encephalopathy and hemiplegia following a stroke. The resident signed the DNR form, followed by the physician and two witnesses on subsequent days. However, the Social Services Supervisor admitted to signing as a witness without actually observing the signing, indicating a failure to ensure the signing was properly witnessed.
A resident with severe cognitive impairment and a history of inappropriate behavior was involved in multiple incidents of alleged abuse. Despite being reported and investigated, the facility failed to implement effective preventive measures. The care plan for the resident was not consistently enforced, and staff were not adequately informed or trained, leading to repeated incidents.
The facility failed to complete PASARR Level II evaluations for two residents with significant mental health diagnoses, despite indications from Level I screenings. The evaluations were delayed due to the facility's physician not providing the necessary signature, as reported by the Social Services Supervisor.
A resident with pressure ulcers did not receive proper care as the facility failed to ensure the functionality of an air mattress pump, a key intervention in the care plan. The pump was found non-functional on several occasions, and staff were unaware of its status, compromising the resident's wound healing process.
A resident with dementia and depression was not provided with a meaningful activity program, despite their interests in exercise, music, TV, and group activities. Observations showed the resident was often left in their room with no engagement, and records indicated minimal participation in activities. The facility's administration failed to explain the lack of engagement in the resident's preferred activities.
A facility failed to ensure monthly drug regimen reviews by a licensed pharmacist and provider for a resident with multiple diagnoses, including schizophrenia and diabetes. Pharmacy recommendations to adjust medication dosages and conduct evaluations were either not addressed or disagreed with without rationale. The provider did not sign medication review forms within the expected timeframe, leading to deficiencies in medication management.
Expired medications were found in a medication cart and storage rooms, including Thiamin Vitamin B-1, Move+Vision+Bones+Supplement, and Calcium Carbonate. The DON stated that nurses checked medications during the night shift, and the central supply person was supposed to help monitor the carts and rooms but did not.
A facility failed to administer an influenza vaccine to a resident with dementia and heart failure, despite receiving verbal consent from the resident's legal guardian. The resident had not received the vaccine since the previous year, and the facility's Director of Nursing confirmed the absence of a record for the vaccine administration after consent was given.
The facility failed to provide proper transfer/discharge notices for two residents, one cognitively intact and the other with moderate cognitive impairment, during hospital transfers. Despite procedures indicating that notices should be given and documented, neither resident nor their representatives received the required notifications, as confirmed by interviews and record reviews.
The facility failed to provide a written bed hold notification in an understandable language to two residents, leading to potential confusion about the bed hold policy. One resident, who was cognitively intact, did not receive documentation during hospital transfers, while another resident's responsible party was not informed of the policy and was told the resident would not be readmitted due to an outstanding balance.
A facility failed to readmit a resident after hospitalization due to an outstanding balance, despite the resident being medically stable for discharge. The resident, with a history of metabolic encephalopathy, diabetes, and heart failure, remained in the hospital while alternative placement was sought. The facility's refusal was confirmed by both the resident's guardian and the hospital's case manager.
The facility failed to date mark potentially hazardous ready-to-eat foods in two resident refrigerators. Observations revealed undated and expired items, including yogurt, salad dressing, and various other food products. The Dining Services Director was unaware of who was responsible for maintaining the refrigerators, and the facility's food storage guidelines were not adhered to.
A resident with a seizure disorder did not receive three doses of acetazolamide due to the medication being misplaced in the cart. The facility failed to notify the physician of the missed doses, and the issue was discovered by the Unit Manager/LPN after being informed by the resident's family.
Food Service Shortages and Poor Meal Presentation
Penalty
Summary
The facility failed to provide palatable food products and failed to provide consistent dietary glassware and flatware for 131 residents who consume food. During dining observations, staff were preparing lunch in the Main Dining Room while limited silverware was available, and several room trays contained plastic silverware mixed with metal silverware. A CNA reported staff had to use plastic silverware when metal silverware ran out during room tray preparation, that the shortage had been an ongoing issue for about one month, and that residents complained because the plastic utensils were difficult to eat with. Staff also reported shortages of blue handled cups with lids, poor-fitting disposable lids, and the need to use two 4-ounce cups when 8-ounce glasses were unavailable. Multiple staff interviews described repeated food shortages and substitutions. A CNA reported the kitchen often ran out of food, including pancakes being replaced with toast, smaller portions when supplies were low, and alternative menu items often not being available. Other staff reported residents frequently complained that food was not what was on the menu, that alternatives such as grilled cheese and mashed potatoes were not available, and that the facility had ongoing problems with food service and kitchen staffing. The grievance log reflected more than 25 kitchen and food complaints related to plastic silverware, food preferences not being honored, lack of alternative choices, lack of cups with lids, food temperatures, and modifications. Resident R73, who had diagnoses including heart disease, CHF, diabetes, diverticulosis, irritable bowel, and depression, was cognitively intact and required meal set-up and clean-up assistance. R73 reported the food was bad, that she had been served hot dogs multiple times, and that she had to eat with plastic silverware several times a week. She also reported weight loss and dissatisfaction with the food. Observations of her meal trays showed mismatches between the meal tickets and the food served, including hot dog and soup items that did not match the ticket, pureed items that appeared inconsistent with the ordered texture, and meals left untouched. Her daughter and staff questioned why certain items were pureed or substituted, and the dietitian confirmed R73 had significant weight loss and that alternate menu items were supposed to be available. Food temperature observations also showed several items below the required hot-holding temperature, including strawberry Bavarian and beverages, while other items were served at varying temperatures. A lunch test tray evaluation found cabbage soup overcooked and mixed together, noodles lacking flavor, and turkey notably dry. Facility policies reviewed stated meals were to be assembled with the needed serving equipment, served in a timely and organized manner, and that nursing staff were to notify Dining Services of missing items or requested substitutes.
Food Service Equipment and Storage Not Properly Cleaned
Penalty
Summary
Food service equipment and related surfaces were not effectively cleaned and maintained in multiple pantry kitchen areas, affecting the food service for 131 residents who consume food. During an initial tour of the food service area with the Dining Service Director, a return-air exhaust ventilation grill near the mechanical dish machine was observed heavily soiled with accumulated and encrusted dust and dirt deposits. In the South Pantry Kitchenette, a microwave oven was observed with an etched, scored, and particulate interior, and the interior door frame and ceiling surface were also etched, scored, and corroded. The same area also contained a Manitowac ice machine with soiled undersplash and backsplash surfaces and a drip tray assembly covered with encrusted mineral deposits, dirt, and food residue. The South Pantry Kitchenette also had a loose hand sink goose neck assembly, and the interior vanity cabinetry was observed severely warped, discolored, moist, and separated from continuous moisture exposure. A red sanitization bucket was stored directly beneath the PVC wastewater plumbing, was completely full of water, and was overflowing onto the interior cabinetry flooring surface. In a separate pantry kitchenette, a Panasonic microwave oven interior was observed soiled with accumulated and encrusted food residue, and a stainless steel commercial toaster interior was also soiled with accumulated and encrusted food residue. During a comprehensive tour of the South Pantry Kitchenette, dietary flatware knives were observed stored inverted in a gray plastic caddy with the food contact surface facing upward. On follow-up tour, the Manitowac ice machine undersplash and backsplash remained soiled with encrusted mineral deposits, water was dripping from the ice dispensing spout into the drip tray, and the flooring directly beneath the ice machine was severely soiled with dust, dirt, and debris including paper products and plastic lids. Facility policy records reviewed described expectations for clean and properly maintained food and non-food surfaces, but the observed conditions showed multiple areas of equipment, storage, and physical facilities that were not maintained in accordance with those standards.
Plastic Silverware and Dining Service Issues
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect when plastic silverware was used for meals, diminishing the homelike dining experience for two residents and potentially affecting all residents who used utensils during meal service. During observation, several residents were seen in the main dining room while staff prepared lunch, and plastic silverware was observed in room trays on carts by the kitchenette. A CNA reported staff used plastic silverware when metal silverware ran out during tray preparation, and that this had been an ongoing issue for about one month that residents complained about because it was difficult to eat with flimsy plastic utensils. One cognitively intact resident, admitted and readmitted to the facility and scored 15/15 on the BIMS, was observed in bed with multiple orange stains on her shirt. She stated she struggled feeding herself lunch because the facility had been using plastic spoons instead of actual silverware, which made it difficult to self-feed without spilling food. She explained that the difference in utensil weight and spoon handle mattered significantly and said the stains on her shirt were from lunch earlier that day. She stated the situation made her feel humiliated. Another cognitively intact resident, who required assistance with meal setup and cleanup, reported that food at the facility was bad and that she was served hot dogs multiple times in one week. She stated she had to eat with plastic silverware two to three times a week and said she should not have to do so after paying a lot of money to be there. During later observations, her meal trays and meal tickets showed inconsistencies between ordered and served foods, including substitutions and altered textures. Staff and dietary personnel also reported shortages of metal silverware, cups, lids, and other dining items, along with frequent food substitutions and unavailable alternatives, and the grievance log reflected more than 25 kitchen and food complaints related to plastic silverware, food preferences not being honored, available alternatives, lack of cups with lids, food temperatures, and modifications.
Inaccurate MDS Assessments for Pressure Injuries, Bed Rails, and ROM
Penalty
Summary
The facility failed to complete accurate MDS assessments for four residents reviewed for MDS accuracy. For one resident, the MDS skin assessment was inconsistent, with the RN marking that the resident did not have pressure ulcers under MO100, then marking that the resident had unhealed pressure ulcers under MO210 and identifying a stage 1 pressure ulcer, while also documenting no dressing use. The resident had diagnoses including a displaced fracture of the left humerus, sequelae of cerebral infarction, type 2 diabetes mellitus, heart failure, and blindness in the right eye, and the most recent MDS also documented the resident as cognitively intact and independent for all care with walker use for safe ambulation. For another resident, the MDS skin assessment did not match the wound information available in the record. The RN documented three DTIs with open areas, but the hospital discharge report and wound documentation showed the resident came to the facility with a stage 3 pressure ulcer of the sacral region, a wound on the left ischium, and a wound on the right buttock. The wound care NP assessment later documented an unstageable sacral pressure wound and two DTIs, not three DTIs. During interview, the RN stated she did not have the wound care NP assessment when completing the MDS and relied on nursing notes for wound details. The facility also inaccurately coded other MDS items for two additional residents. For one resident with diagnoses including stroke, dementia, COPD, dysphagia, diabetes, hypothyroidism, anemia, depression, psychosis, hyperlipidemia, hypertension, anxiety, and insomnia, the MDS coded bed rails as not used even though the resident was observed in bed with half side rails on both sides, and there was no order, care plan entry, or side rail evaluation in the record. For another resident with a history of cerebral vascular accident affecting the left side, heart disease, anxiety, and depression, the MDS documented no upper extremity range of motion impairment even though the resident had left arm contractures and therapy staff confirmed ongoing left-side impairment and that the MDS ROM coding was incorrect.
Missing Orthostatic BP Monitoring for Resident on Antipsychotic
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident prescribed an antipsychotic medication. Resident #93 was admitted and later readmitted with diagnoses including a nondisplaced bimalleolar fracture of the right lower leg, and the MDS dated 9/23/25 showed severe cognitive impairment with a BIMS score of 7 out of 15. On 12/10/2025, the resident was observed in her room watching television. Review of the physician orders showed an active order for Seroquel 50 mg, and the antipsychotic medication care plan included an intervention for orthostatic blood pressures as ordered. However, there was no physician order for orthostatic blood pressures and no completed orthostatic blood pressure monitoring documented in the vital signs record. During interview, the DON stated that residents taking antipsychotic medications require specific monitoring, including orthostatic blood pressure monitoring once a month, and confirmed the absence of this monitoring in the resident’s electronic medical record.
Care Plan Did Not Reflect Use of Bed Rails
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident admitted with multiple diagnoses including cerebral infarction, dementia, COPD, dysphagia, type 2 diabetes, hypothyroidism, anemia, depression, psychosis, hyperlipidemia, hypertension, anxiety, and insomnia. The resident’s MDS showed severe cognitive impairment with a BIMS score of 07 out of 15. During observation, the resident was lying in bed with a half-length side rail on the right side and a half-length side rail on the left side, and the resident did not respond to verbal questions. The resident’s MDS coded bed rails as not used, but the care plan did not include bilateral side rails and the physician orders did not include an order for side rails. The medical record also did not show a side rail evaluation or measurements of the bilateral side rails. The DON confirmed that the resident did not have the required documentation completed, and the MDS Coordinator confirmed that the MDS and care plan did not reflect the observed side rails.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide baths/showers for one resident who was unable to perform activities of daily living independently. Resident #13 was admitted with diagnoses including cerebral infarction, schizoaffective disorder depressive, dementia, COPD, atrial flutter, sleep disorder, hypertension, hyperlipidemia, and anxiety. The resident’s MDS showed a BIMS score of 09, indicating severe cognitive impairment, and section GG showed she was dependent for showers. During observation and interview, the resident stated she had not been receiving showers as often as she wanted and said she wanted to shower twice per week. The resident’s point-of-care task indicated showers were scheduled for Wednesday and Sunday evenings. The CNA explained that shower assignments were provided on paper and documented on shower sheets, which were given to nurses. The DON stated residents were to receive baths/showers according to their plan of care and confirmed the resident was to receive two showers per week on Wednesday and Sunday afternoon/night shift. Review of the resident’s skin assessment sheets showed multiple dates with no shower documentation, including 10/08/25, 10/12/25, 10/15/25, 10/27/25, 11/02/25, 11/05/25, 11/09/25, 11/23/25, 12/03/25, and 12/10/25. The DON stated 11 showers were completed out of a possible 21 days from October through the present date and could not explain why showers had not been completed as directed by the plan of care.
Failure to Provide Meaningful In-Room Activities
Penalty
Summary
The facility failed to provide meaningful activities to one resident, R86, resulting in boredom, isolation, and disengagement. R86 was admitted with diagnoses including traumatic subdural hemorrhage without loss of consciousness, fracture of the left great toe, emphysema, atrial fibrillation, heart failure, dyspnea, and repeated falls. The most recent MDS showed a BIMS of 14, indicating she was cognitively intact, and GG data reflected impairment on both sides, use of a walker and wheelchair for ambulation, and substantial to maximal assistance needed for all care. During an observation and interview, R86 did not have activities, magazines, books, or coloring materials in her room and stated nobody had talked to her about bringing activities to her room because it was painful to go down to activities off her floor. R86 and her daughter stated no one had come by that morning to include her in activities, and R86 said activities did not do anything with her in her room. She also stated she did not have a calendar to show what activities were offered. The activity aide stated check-ins consisted of stopping in the room to see if residents needed anything and that 1:1 visits lasted about 10 to 15 minutes. The Activity Director stated activity staff could provide in-room visits and check-ins, but also stated preferences had been reviewed with the daughter rather than directly with R86, who was of sound body and mind. The Activity Director said the activity calendar should have been posted on the magnetic whiteboard at the end of R86's bed, but no calendar was observed there.
Unsafe Mechanical Lift Transfer Resulted in Resident Leg Laceration
Penalty
Summary
The facility failed to ensure resident safety during a staff-assisted mechanical lift transfer for a resident who was dependent for transfers and required staff assistance with dressing, hygiene, bathing, and transfers. The resident had diagnoses including chronic osteomyelitis, heart failure, morbid obesity, diabetes, venous insufficiency, and depression, and her MDS reflected a BIM score of 15, indicating she was cognitively intact and able to make daily decisions. Her care plan directed that she be transferred dependent x 2 with a mechanical lift and blue/XL trim sling. During the transfer from bed to wheelchair, staff attempted to reposition the resident while she was in the lift because she was leaning to the left. The lift tipped when one leg came off the ground, and staff then noticed a large stream of dark red blood from the resident’s right lower leg. The progress note stated the resident had an upside down J-shaped laceration approximately seven cm long on the right calf, and the resident was sent to the hospital where she received four stitches to the right lower shin. The resident reported that three staff were present during the incident and that the lift tipped over during the transfer. Interviews with staff showed differing descriptions of the transfer, but all indicated the resident was being moved with a mechanical lift and that the lift was not positioned correctly. Staff reported the lift legs were not in the widest position and that the lift was positioned between the front and back wheel of the wheelchair rather than directly in front of it. One CNA stated the resident required two to three staff for mechanical lift transfers and never one, while another reported the minimum safe transfer required two people. The facility policy also stated the minimum number for a safe mechanical lift transfer is two people and that the base should be spread wide open under the bed with the wheelchair in position and brakes locked.
Failure to Document and Monitor Nutrition Interventions for Residents with Weight Loss
Penalty
Summary
The facility failed to implement and document interventions intended to prevent further weight loss for two residents, including consistent monitoring of meal intake, nutritional supplements, and snacks. Resident #10 had diagnoses including Alzheimer’s disease, anxiety disorder, and insomnia, was severely cognitively impaired with a BIMS score of 0/15, and required setup or clean-up assistance with eating. The resident was on a mechanically altered diet and had a documented 6.29% weight loss from 127.2 pounds to 119.2 pounds over about one month. For Resident #10, the nutrition assessment noted inconsistent intake and recommended snacks three times daily and Magic Cup twice daily, but there were no physician orders for those interventions. The care plan directed staff to provide and serve supplements and snacks as ordered and to monitor and record every meal, yet the record showed numerous missing meal intake entries, multiple supplement documentation gaps, and no snack documentation in the last 30 days. The resident was also observed wandering while other residents were eating applesauce and drinking coffee, and staff did not redirect the resident into the lounge for a snack and coffee. Meal tickets also reflected a pork entrée despite a documented dislike for pork. Resident #116, who had dementia and was interviewable and appropriate, had a documented 12.4% weight loss over six months and was receiving a fortified smoothie and a nighttime snack for variable intake and weight loss. Observations and interviews showed the resident did not consume the smoothies, with one smoothie left untouched at the bedside and the resident and family member stating the smoothies were not eaten. The record showed inconsistent completion of meal and supplement intake documentation, repeated use of "not applicable" for supplement intake, and no evidence that the nighttime snack was being provided or that snack acceptance or consumption was documented.
Bed Rail Use Not Assessed or Documented
Penalty
Summary
The facility failed to ensure that bed rails were assessed and measured to prevent possible entrapment for one resident. Resident #7 was admitted with diagnoses including cerebral infarction, dementia, COPD, dysphagia, type 2 diabetes, hypothyroidism, anemia, depression, psychosis, hyperlipidemia, hypertension, anxiety, and insomnia. The resident’s MDS showed a BIMS score of 7, indicating severe cognitive impairment. During observation, the resident was lying in bed with a half-length side rail on both the right and left sides, and the resident did not respond to verbal questions. Record review showed the resident’s MDS coded bed rails as not used, the care plan did not include bilateral side rails, and there was no physician order for side rails. The medical record also did not show a side rail evaluation or measurements of the bilateral side rails. The DON confirmed that the required assist device/bed rail assessment, 5-day monitoring form, physician order, and care plan documentation were not present in the record, and the MDS Coordinator confirmed the MDS and care plan did not reflect the observed side rails.
Bed Rails Not Documented or Monitored
Penalty
Summary
The facility failed to ensure monitoring and inspection of a resident’s bed frame and mattress for one resident reviewed for bed safety. The resident was admitted with diagnoses including cerebral infarction, dementia, COPD, dysphagia, type 2 diabetes, hypothyroidism, anemia, depression, psychosis, hyperlipidemia, hypertension, anxiety, and insomnia. The resident’s MDS showed severe cognitive impairment with a BIMS score of 07 out of 15, and during observation the resident was lying in bed with half-length side rails on both the right and left sides. The resident did not respond to verbal questions during the attempted interview. The resident’s MDS coded bed rails as not used, and the care plan did not include bilateral side rails. The physician orders also did not include an order for side rails, and the medical record did not show a side rail evaluation or measurements of the bilateral side rails. The DON confirmed that residents using side rails should have an assist device/bed rail assessment, a 5-day monitoring form, a physician order, and a care plan entry, and confirmed that none of these were documented for the resident. The MDS Coordinator also confirmed the MDS and care plan did not reflect the observed side rails and could not explain the discrepancy.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to develop and/or implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. Resident 136 was admitted with diagnoses including congestive heart failure and chronic kidney disease and was cognitively intact with a BIMS score of 15 out of 15. The resident reported that while receiving frequent nighttime assistance for toileting due to diuretic use, a CNA became angry about repeated call light use, refused to identify herself, and later handled the resident roughly by shoving a bedpan hard into the resident’s hip, causing significant pain and a large bruise that led to an emergency room visit the next morning. The resident reported the incident to the midnight nurse and later to LPN P, who observed the resident tearful with extreme right hip pain and a large edematous area on the right hip, and the physician and abuse hotline were called. LPN P stated the resident clearly described the act as intentional abuse and that the allegation was reported per protocol. However, LPN Q stated she did not report the incident to the State Agency because she believed the injury was related to positioning and said the resident was known to change her story, despite there being no care plan identifying the resident as having behavior problems such as changing her story or making false accusations. The facility policy required alleged violations to be reported to the Administrator, State Agency, adult protective services, and other required agencies within specified time frames.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a cognitively intact resident who had diagnoses including congestive heart failure and chronic kidney disease. The resident reported that while using a diuretic and needing frequent assistance with a bedpan during the midnight shift, a CNA became angry, refused to identify herself, and later handled her roughly by shoving the bedpan hard into her hip. The resident stated the incident caused significant pain and a large bruise that led to an emergency room visit the next morning. She also reported that she told the midnight nurse about the rough treatment and then told an LPN the following morning that the CNA had been mad and intentionally caused the injury. The unusual occurrence report documented that the resident was tearful, complained of extreme right hip pain, and had a large edematous area on her right hip, with the physician and abuse hotline notified. However, the investigation file did not include an interview with the resident, and the investigator stated the resident was not interviewed because she was at the hospital, although she was not admitted. The investigator also stated the injury was determined to be a positioning issue rather than abuse, and later said the resident was known to change her story, despite no care plan identifying such behavior. The facility policy required an immediate investigation and interviewing the alleged victim and alleged perpetrators when abuse was suspected.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen's reach-in cooler, several food items were found with expired use-by dates, including chicken, pureed vegetables, blue cheese dressing, and pureed pasta. Additionally, an unlabeled and undated container of food was discovered. Similar issues were observed in the rehab kitchen, where a cloth hamper was overflowing with soiled rags and aprons, attracting fruit flies. The reach-in cooler in the rehab kitchen contained expired items such as coffee creamer, thickened water, smoothies, barbeque sauce, ketchup, and vanilla pudding. The dry storage area also had expired dry cereal, and the walk-in cooler contained a tray of bedtime snacks and other items past their use-by dates. The Dining Services Manager acknowledged these issues and removed the expired and undated items. Further deficiencies were noted in the temperature control of food items. During a meal service observation, the temperature of a chicken breast on the steam table was found to be 123 degrees Fahrenheit, which was below the required temperature for safe consumption. A subsequent test tray revealed that the chicken breast, potatoes, and green beans were all served at temperatures below the required 135 degrees Fahrenheit, with the milk being slightly above the safe temperature of 41 degrees Fahrenheit. These findings indicate a failure to maintain proper time/temperature control for safety food, as specified by the 2017 FDA Food Code.
Failure to Ensure Proper Witnessing of DNR Document
Penalty
Summary
The facility failed to ensure that witnesses observed the signing of a Do-Not-Resuscitate (DNR) document for a resident. The resident, who had been admitted and readmitted to the facility with diagnoses including encephalopathy and left side hemiplegia and hemiparesis following a stroke, signed the DNR form on March 1, 2024. The physician signed the form on March 5, 2024, and two witnesses signed on March 6, 2024. The Attestation of Witnesses section of the DNR document indicated that the individual appeared to be of sound mind and under no duress, fraud, or undue influence. However, during an interview, the Social Services Supervisor reported that they would sign as a witness if they talked to the person who signed the DNR document, even if they did not actually witness the signing. This indicates a failure to ensure that the signing was properly witnessed as required.
Inadequate Response to Allegations of Abuse
Penalty
Summary
The facility failed to implement appropriate preventive measures and take corrective action for allegations of abuse involving three residents. Resident #33 reported being molested by another resident, #113, during a bingo game. Despite the incident being reported and investigated, the only measure taken was to seat Resident #113 a few tables away during bingo. The facility's response was inadequate as Resident #113, who has a history of sexually inappropriate behavior, was not properly monitored or restricted from interacting with female residents. Resident #113, with severe cognitive impairment and a history of inappropriate behavior, was involved in multiple incidents of alleged abuse. During a bingo game, Resident #113 allegedly touched Resident #33 inappropriately, which was witnessed by an Activity Aide. The aide intervened by seating another aide between the two residents but did not report any further preventive measures. Additionally, Resident #113 was involved in another incident with Resident #9, where inappropriate touching was reported. The facility's investigation revealed that Resident #113 was unable to recall the incident due to cognitive deficits. The facility's care plan for Resident #113, which included interventions to prevent inappropriate behavior, was not effectively implemented. The care plan was updated to include monitoring and redirecting Resident #113 away from female residents, but these measures were not consistently enforced. Staff members, including a Resident Aide, were not adequately informed or trained on the specific interventions required to manage Resident #113's behavior, leading to repeated incidents of abuse.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a Level II determination was completed for two residents, both of whom had significant mental health diagnoses. Resident #83 was admitted with diagnoses including schizoaffective disorder and dementia with psychotic disturbance. Despite being prescribed antipsychotic and antidepressant medications, the resident did not have a Level II evaluation or exemption completed, even though the PASARR Level I Screening indicated the need for further evaluation. Similarly, Resident #104, who was admitted with PTSD, vascular dementia, and severe cognitive impairment, also lacked a Level II evaluation or exemption, despite the PASARR Level I Screening indicating the necessity for it. The deficiency was further highlighted during an interview with the Social Services Supervisor, who reported that the Level II evaluations for both residents were still in progress according to the Community Mental Health Services Program's (CMHSP) website. However, the evaluations had not been completed because the facility's physician had not yet provided their signature, which was necessary for the process to move forward. This oversight resulted in the facility's failure to comply with the required PASARR process for residents with mental disorders or intellectual disabilities.
Failure to Implement Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to implement care planned interventions for a resident with pressure ulcers, leading to a deficiency in wound care management. The resident, who was admitted with a stage four pressure ulcer and an unstageable pressure ulcer, was dependent on two staff members for repositioning and turning in bed. The care plan included the use of an alternating pressure mattress to promote healing. However, observations revealed that the air mattress pump was not functioning on multiple occasions, as indicated by the absence of illuminated lights on the pump. The resident reported that the mattress was sometimes soft and that staff occasionally unplugged the air mattress when moving the bed. Further investigation showed that a Licensed Practical Nurse (LPN) discovered the air mattress pump was off and, upon reconnecting the power cord, the pump turned on. The LPN was unaware of how long the pump had been off. A Registered Nurse (RN) confirmed the purpose of the air mattress was to alleviate pressure, yet the pump was observed to be non-functional again the following day. This lack of consistent functionality of the air mattress pump indicates a failure to adhere to the care plan designed to support the resident's wound healing process.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide a meaningful, diverse, and engaging activity program for a resident diagnosed with dementia and depression, who was admitted with long and short-term memory impairment and severely impaired decision-making skills. Observations over several days revealed the resident was repeatedly left in their room, sitting in a wheelchair against the wall with the television off and no music playing. Despite the resident's activity assessment indicating interests in exercise, music, TV, movies, outdoor activities, and group interactions, there was no evidence of participation in these activities over the past 30 days, except for minimal one-on-one interactions. The activity participation records showed limited engagement, with only a few instances of conversation and TV watching. During an interview, the Nursing Home Administrator and Activity Director acknowledged that activity participation records were being trialed through a new computer program but failed to provide a clear explanation for the lack of engagement in the resident's preferred activities. There was no documentation indicating that the resident had been invited to or refused any activities of interest, highlighting a deficiency in meeting the resident's needs for meaningful engagement.
Failure in Monthly Drug Regimen Review and Provider Response
Penalty
Summary
The facility failed to ensure that drug regimens were reviewed at least once a month by a licensed pharmacist and provider for one of the residents reviewed for medication management and monitoring. The resident, who was initially admitted to the facility with diagnoses including anxiety, schizophrenia, diabetes mellitus, and coronary artery disease, had several instances where pharmacy recommendations were not appropriately addressed by the provider. For example, recommendations to adjust the dosage of Eliquis and to conduct an abnormal involuntary movement evaluation were either disagreed with without rationale or not responded to at all. Additionally, there were instances where the provider did not sign the medication review forms within the expected timeframe, and some recommendations, such as discontinuing certain medications or adjusting dosages, were left unaddressed. The Director of Nursing (DON) acknowledged that the Nurse Practitioner responsible for these oversights had been terminated and noted that the expectation was for providers to respond to pharmacy recommendations within 7 days, or 30 days at the latest. However, this expectation was not met, leading to the deficiency in medication management for the resident.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to properly dispose of expired medications, as observed in one of four medication carts and one of three medication storage rooms. During an observation, a bottle of Thiamin Vitamin B-1 100mg with an expiration date of March 2024 was found on the Blue Cart. Additionally, in the Blue Medication Room, a bottle of Move+Vision+Bones+Supplement expired in April 2024 was observed. Furthermore, in the [NAME] Ridge Medication Room, two bottles of Calcium Carbonate 500mg with an expiration date of April 2024 were found. During an interview, the Director of Nursing (DON) B stated that nurses were responsible for checking medications during the night shift. DON B also mentioned that the central supply person was supposed to assist in monitoring the medication carts and rooms, but they did not check the carts and rooms as expected.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to administer an influenza immunization to Resident #46, despite having received consent from the resident's legal guardian. Resident #46, who was admitted with diagnoses including dementia and heart failure, had moderately impaired cognitive skills and required a legal guardian for decision-making. The facility attempted to obtain consent for the influenza vaccine by leaving messages and sending a letter to the guardian, but received no reply initially. After the resident was hospitalized and returned to the facility, verbal consent for the influenza immunization was given by the guardian on 10/25/23. However, the facility did not administer the vaccine, and the last recorded influenza immunization for the resident was on 10/13/22. The Director of Nursing confirmed that there was no record of the vaccine being administered after consent was obtained.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to meet transfer and discharge documentation requirements for two residents, resulting in the potential for these residents and/or their representatives not obtaining their due rights. Resident 39, who was cognitively intact, was transferred to the hospital twice without receiving a transfer/discharge notice. The nursing home administrator stated that the admissions office was responsible for the bed hold policy and transfer notices, while a licensed practical nurse indicated that a transfer/discharge/bed hold packet should be given to the resident or family and scanned into the chart. However, there was no documentation of the notice being provided to Resident 39. Similarly, Resident 19, who had moderate cognitive impairment, was transferred to the hospital without a transfer/discharge notice being provided to the responsible party. Although the facility later provided a Transfer Notice Form and claimed that the notice was mailed to the resident's guardian, the guardian reported not receiving it. These deficiencies highlight a failure in the facility's process for ensuring that residents and their representatives are properly notified of transfers or discharges, as required by regulations.
Failure to Provide Bed Hold Notification in Understandable Language
Penalty
Summary
The facility failed to provide a written bed hold notification to two residents, R39 and R19, in a language that was understandable, which resulted in a potential lack of understanding of the bed hold policy. For Resident 39, who was cognitively intact and required maximum assistance with personal care, there was no documentation of a transfer/discharge/bed hold notice being provided during two hospital transfers. Interviews with the Nursing Home Administrator and a Licensed Practical Nurse revealed that the responsibility for providing these notices was part of the admissions office role, and a template was available but not documented in the resident's chart. For Resident 19, who had moderate cognitive impairment, there was no documentation of a bed hold notice being provided to the responsible party upon transfer to the hospital. The Admissions Director reported that the facility called the responsible party within 24 hours of the resident leaving, but the Guardian stated they were not notified of the bed hold policy. Instead, they were informed that the facility would not readmit the resident due to an outstanding balance. A Social Services Supervisor confirmed a conversation with the Guardian about the non-readmission due to payment issues.
Facility Fails to Readmit Resident Due to Payment Issues
Penalty
Summary
The facility failed to permit timely readmission for a resident after hospitalization, which led to a deficiency. The resident, who had a history of metabolic encephalopathy, diabetes, and heart failure, was initially admitted to the facility and later transferred to the hospital due to being unresponsive. The hospital determined the resident was stable for discharge, but the facility declined readmission due to an outstanding balance, as reported by the resident's guardian and confirmed by the facility's Social Services Supervisor. The hospital's case manager also reported that the facility's admissions department refused the resident's return, citing payment issues. Consequently, the resident remained in the hospital while alternative placement was sought, despite being medically stable for discharge. This situation persisted until the resident was eventually discharged back to the facility, highlighting the facility's failure to adhere to regulations regarding resident readmission after hospitalization.
Failure to Date Mark Ready-to-Eat Foods in Resident Refrigerators
Penalty
Summary
The facility failed to date mark all potentially hazardous ready-to-eat food products in two of the three resident refrigerators reviewed. During an observation of the rehab unit resident refrigerator, several items were found undated, including a bowl of unknown food, a squirt bottle of salad dressing, a bowl of peas, a cup of milk, a container of salad, and a container of thickened orange juice. Additionally, expired items such as Chobani blueberry Greek yogurt and a container of roasted turkey BLT from the facility's bistro were found. The Dining Services Director (DSD) was unaware of who was responsible for maintaining the resident refrigerators. In the memory care unit resident refrigerator, similar issues were observed, with several undated items including seven bowls of food, an opened container of thick and easy, chocolate syrup, two half gallons of chocolate milk, two cups of orange juice, and a mighty shake. An opened med pass fortified nutritional shake was dated but not within the acceptable timeframe. The DSD confirmed that the foods were not labeled and/or expired. The facility's Dining Services Food Storage Chart, which was posted on the front of the rehab unit refrigerator, outlined specific storage timelines for various food items, but these guidelines were not followed, leading to the deficiency.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of acetazolamide, a medication prescribed for seizure disorder. The resident, who was diagnosed with seizure disorder and muscular dystrophy, did not receive the prescribed doses of acetazolamide on two occasions. The medication was not administered in the afternoon and evening on one day and the following morning. Nursing notes indicated that the medication was not available, and there was no documentation that the physician had been notified of the missed doses. The incident report revealed that the medication was actually present in the medication cart but had been placed backward and in the wrong slot, leading to the oversight. The Unit Manager/LPN became aware of the missed doses through the resident's family and subsequently found the misplaced medication in the cart. Despite attempts to contact the responsible nurses, no explanation was provided as to why the physician was not informed of the missed doses.
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What surveyors actually found near you
We read the 153 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Okemos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Willows At Okemos | 2 mi | ★★★★★ | 7 | 0 |
| Medilodge Of Okemos | 2.8 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Campus Area | 3.2 mi | ★★★★★ | 11 | 0 |
| Burcham Hills Retirement Center | 3.9 mi | ★★★★★ | 4 | 0 |
| Medilodge Of East Lansing | 5 mi | ★★★★★ | 28 | 0 |
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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.