Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Iosco County Medical Care Facility during CMS and state inspections, most recent first.
A facility failed to prevent and monitor pressure injuries for two residents. One resident with dementia, hemiplegia, and total ADL dependence had a gluteal pressure injury that worsened from DTI to Stage II and then unstageable, while staff did not consistently reposition the resident and the resident was observed sitting upright in a recliner without a pressure-reduction cushion. Another resident, admitted after leg fracture surgery and cellulitis, was found with a large heel DTI and a right gluteal Stage II wound, but the heel injury was not documented on admission and had no care plan addressing the location or treatment.
The facility failed to maintain adequate QAPI/QAA policies and procedures for data collection, analysis, and feedback, with only a single outdated QA policy available and no other written guidance found. The NHA reported limited PIPs, including one for call lights and a discontinued pressure ulcer PIP, while survey review also found CNA pager issues, resident complaints that call lights were being shut off without follow-up, no documented antibiotic education for MDs or NPs, and the contracted pharmacist absent from QAPI meetings for more than 6 months.
Failure to maintain effective QAPI oversight was identified when the facility had only an outdated QA policy, no other QA data collection or feedback policies, and no sustained PIP process for pressure ulcers despite repeated survey concerns. A resident was observed with an open area on the gluteus and a deep tissue injury on the heel, staff were unaware of the heel injury until the surveyor found it, CNA pagers were not working or not being carried, and call lights were reportedly being shut off without follow-through. The antibiotic stewardship program also lacked documented education for the MD/NPs and had limited pharmacist participation in QAPI.
The facility failed to operationalize its infection control program during meal service and resident care. A CNA was observed serving breakfast on the dementia unit without hand hygiene and passing brown sugar between residents’ bowls, and a resident with an indwelling urinary catheter was found with the drainage bag on the floor without a barrier. The facility also had multiple unused or out-of-order plumbing fixtures and staff reported chlorine residual was not being tested, despite the Water Management Plan requiring flushing of unused piping and monthly disinfectant monitoring.
A facility failed to maintain a functional antibiotic stewardship program because its CAI and HAI line lists did not show whether antibiotics met criteria, and the monthly IC summary did not address appropriateness or follow-up for inappropriate use. One resident received repeated and prophylactic antibiotics without documented risk-versus-benefit review, another resident received prophylactic trimethoprim without a documented reason or infection, and a third resident was started on 2 antibiotics for UTI before culture results showed no growth, with no physician rationale documented.
Call lights were not kept within reach and were often answered far beyond the facility’s stated response times. Several residents with significant care needs, confusion, or sensory impairment were observed with call devices out of reach, and one resident reported waits of over 30 minutes. Resident council and group feedback described long delays, including one resident becoming incontinent because no one answered the light, while facility records showed repeated response times over 20 minutes, over an hour, and one call answered after more than 8 hours.
Insufficient staffing and delayed call light response: A resident reported long waits for assistance, and call light logs showed repeated delays, including one over an hour. In the Little House unit, surveyors observed one CNA handling meals, ADLs, activities, and call lights while the nurse was mainly in the main building passing meds. Staff said they were often alone, had no coverage for breaks, and could not always respond promptly to resident needs.
Incomplete discharge documentation and communication: A resident with a surgical site infection, right-sided hemiplegia, and a hx of kidney transplant was discharged after the spouse took the resident to another hospital. The EMR lacked transfer/discharge assessment documentation, and the DON and Administrator could not provide documentation of what information was sent with the resident or any follow-up communication.
Failure to Complete Annual PASARR Review: The facility failed to ensure PASARR completion for a resident with dementia, anxiety, depression, psychosis, and severe cognitive impairment. The resident had PASARR Level I and II screenings completed by the hospital before admission, but staff stated the annual PASARR reviews were behind. The Social Services Director and Administrator both acknowledged the annual requirement and the facility's backlog, and no PASARR policy or procedure was provided during the survey.
A resident with multiple serious diagnoses, including CHF, chronic lung disease, acute kidney failure with a urinary catheter, and stroke, had an indwelling urinary catheter care plan that directed the drainage bag not touch the floor. During observation, the resident was sleeping in bed while the catheter bag sat on the floor next to the bed with no barrier underneath it. An Infection Control RN stated the bag should not be on the floor and needed a barrier under it.
A resident admitted after surgery for a leg fracture and cellulitis developed a left heel deep tissue injury, but the care plan, Kardex, and admission assessment did not reflect the injury or the heel-up device in use. The family reported the heel wound had been present for weeks, and surveyors observed a large dark non-blanchable area on the heel while staff stated they had just discovered it. The DON acknowledged the care plan documentation did not include the heel injury details.
A resident with macular degeneration and hearing deficit was found without effective access to glasses or hearing aids, and the resident reported being unable to see or hear well and having no audiology follow-up. The resident was observed without glasses in the room, stated the new glasses did not help, and said the hearing aids did not work. Record review showed limited documentation of vision/hearing support, no audiology consult documentation in the EMR, and the DON confirmed the resident had not been seen by audiology despite consults being sent.
Failure to Monitor Anticoagulation Therapy: A resident receiving apixaban for atrial fibrillation had no documented monitoring for bleeding or other anticoagulation side effects in the EMR, and no care plan related to anticoagulant therapy. The DON confirmed the resident was on an anticoagulant and stated the monitoring task was not reordered after readmission.
Food Service Sanitation and Hand Hygiene Deficiencies: Surveyors observed an expired carton of Lactaid in the walk-in refrigerator, a visibly soiled and rusting slicer that had not been used in 2 years, a soiled mixer, crumbs on pans stored under the counter, and multiple dirty appliances in the Small House kitchen including a microwave, oven, and toaster. During food service and tray prep, an employee was observed changing gloves without washing hands, despite facility policy requiring hand hygiene before donning gloves and after removing them.
A facility failed to issue a beneficiary notice (ABN/NOMNIC) to a resident who transitioned to hospice services, leading to potential financial hardship. The forms were not signed due to the family's choice of hospice, and the facility lacked a policy for issuing these notices. The Nursing Home Administrator confirmed that a policy was being developed but was not yet ready.
The facility failed to update care plans for two residents, resulting in delayed nursing interventions and inadequate care. One resident with a pressure ulcer did not have an updated care plan, and communication between nursing and rehab staff was lacking. Another resident experienced delays in assistance for toileting and bathing, with inadequate documentation of care due to discontinued use of shower sheets.
A facility failed to provide scheduled showers for a resident requiring substantial assistance post-hip surgery. The resident, needing maximal help for ADLs, was scheduled for bi-weekly showers but received only three documented showers over 21 days. A CNA admitted to missing showers due to being reassigned and noted inadequate documentation practices.
A resident with severe cognitive decline developed a Stage II pressure ulcer on the coccyx due to the facility's failure to implement preventive measures and timely identification. The wound nurse noted a reddened area but did not document it, and preventive measures like a pressure reduction cushion were not in place. Inadequate documentation and communication, including the lack of a system for reporting skin concerns during showers, contributed to the delay in identifying the ulcer.
Two residents in an LTC facility experienced repeated falls due to inadequate supervision and ineffective implementation of fall prevention policies. One resident, with multiple medical conditions including dementia, sustained a head injury requiring emergency care. The facility failed to conduct continuous neurological assessments and did not adjust medication regimens despite known risks. The facility's fall prevention policy was not effectively executed, leading to repeated falls and injuries.
The facility failed to ensure residents were free from unnecessary medications and did not obtain consent for antidepressant use. A resident received Ativan without a stop date, and another received antidepressants without consent. The facility's policy required informed consent and evaluation of psychotropic medications, which was not followed.
The facility failed to follow medication labeling and storage policies, with observations revealing unlabeled and undated medications in three medication carts. An LPN was found pre-setting probiotics without labels, and multiple medications lacked open or expiration dates. Unsanitary conditions were noted in the carts, with debris and loose tablets present. Additionally, inconsistencies in medication refrigerator temperature logs were identified, indicating lapses in medication management practices.
Failure to Prevent and Track Pressure Injuries
Penalty
Summary
The facility failed to implement interventions to prevent pressure ulcer development and deterioration for two residents. One resident had dementia, depression, anxiety, and left-sided hemiplegia/hemiparesis after a stroke, was severely cognitively impaired, and required total assistance for ADLs except eating. The resident had a history of pressure ulcers and was documented as at risk for pressure ulcer development. On observation, the resident was sitting in a wheelchair in the common area for an extended period without being repositioned, and later was observed sitting in a recliner without a pressure reduction cushion in place. Staff interviews indicated the resident was dependent on staff for repositioning, but repositioning in the recliner was not being done regularly, and staff stated the resident was supposed to be repositioned more frequently than the care plan reflected. Record review for that resident showed a left buttock/gluteal pressure injury that progressed from a deep tissue injury to suspected deep tissue injury, then to Stage II, and later to unstageable with 100% slough. Documentation also noted deterioration, stalled healing, redness/inflammation, induration, and evidence of infection. The care plan included a gel/foam wheelchair cushion, an air mattress, and laying the resident down after meals, with repositioning every 2 hours, but staff interviews indicated the resident was actually being kept upright in the recliner and repositioned only every couple of hours in the wheelchair, with little or no repositioning in the recliner. The record also showed no new nutritional supplements were implemented after the pressure ulcer developed, despite the worsening wound. The second resident was admitted after left leg fracture surgery and cellulitis and was dependent on staff for ADLs. On observation, the resident had a large brown/purple deep tissue injury on the left heel, and family stated a nurse had previously found the dark spot and placed a heel-offloading device on the bed. Record review showed no mention of the heel injury on admission assessment and no care plan addressing the pressure injury location or treatment. During wound care observation, staff also identified a right gluteal wound with serosanguinous drainage that had been described as a facility-acquired Stage II pressure ulcer. Staff interviews stated the resident often did not want to move because of leg pain, sometimes requested to return to bed, and the heel injury had gone unnoticed until the surveyor observed it. The DON and wound care staff stated there was no documented heel pressure injury care plan and that the resident’s pressure area had not been identified in the care plans.
QAPI Program Lacked Policies, Data Processes, and Consistent Interdisciplinary Participation
Penalty
Summary
The facility failed to have policies and procedures for data collection, analysis, and feedback for its QAPI/QAA program. During interview and record review, the Nursing Home Administrator/QA coordinator stated that the only QA policy available was a single page policy dated 12/13/2016 from the previous administration, and that no other policies for the QA program had been updated during the past year. The NHA also stated that there were no other policies for data collection, analysis, or feedback on QA issues or concerns that could be found. The QAPI process review also showed that the facility had identified concerns including pressure ulcers, call lights, antibiotic stewardship, infection control, and falls, but only one PIP was active for call lights. The NHA stated that a prior pressure ulcer PIP had been stopped after improvement, despite a reported issue with pressure ulcers the day before the survey. The surveyor also found that CNA pagers were not being reliably used because staff were losing them, leaving them at home, or not changing batteries, and the NHA was unaware of residents' reports that CNAs were shutting off call lights and not returning. In addition, the contracted pharmacist had not attended QAPI meetings for over 6 months, with sign-in sheets showing attendance only once during the reviewed period, and there was no documented antibiotic education for physicians or nurse practitioners despite antibiotic stewardship being discussed and previously cited.
Failure to Maintain Effective QAPI Oversight
Penalty
Summary
The facility failed to sustain an ongoing quality assessment and assurance system to review quality deficiencies and develop corrective plans of action for all 49 residents. During interview and record review, the Nursing Home Administrator/QA coordinator stated that the facility only had one QA policy from the previous administration, signed 12/13/2016, and that no other QA policies for data collection, analysis, or feedback on QA issues could be found. The NHA also stated that the facility had only one current PIP on call lights and that a prior PIP on pressure ulcers had been stopped after it improved, even though a pressure ulcer issue had been identified again the day before the interview. Survey findings included repeated concerns related to pressure ulcers/injuries and antibiotic stewardship. Resident #22 was observed with an open area on the right gluteus with slight serosanguinous drainage, and the RNs were surprised when the resident's left heel was found to have a large dark non-blanchable area identified as a deep tissue injury; the family member stated the heel sore had been present for over 3 weeks and that a former nurse had previously placed a heels-up device/pad. The surveyor also observed concerns with call light response, including CNA pagers not working or not being carried by staff, dead batteries, pagers left on the nursing station desk, and reports that CNAs were shutting off call lights and not returning. For antibiotic stewardship, the NHA acknowledged the program had been cited the prior year and would be cited again, there was no documented antibiotic education for the physician or nurse practitioners, pharmacist consultant attendance at QAPI meetings was limited, and the facility had no documented policies beyond the antibiotic stewardship policy dated 10/26/2024.
Infection Control Program and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection control program, including outcome surveillance, accurate data collection, documentation, analysis, and infection control measures during meal service for residents in the Woodland 400 dementia unit and the Little House unit. During breakfast observation on the Woodland 400 dementia unit, a CNA was observed setting up meal trays from a hot box, serving residents, returning to the hot box, and moving to the next resident without hand hygiene. The CNA also passed brown sugar from resident to resident, touching bowls and stirring oatmeal, and no hand hygiene was observed during these actions. The facility also failed to maintain infection control practices related to resident care and environmental conditions. A resident with diagnoses including MI, anemia, pneumonia, back pain, malignant neoplasm of the kidney, chronic lung and heart failure, acute kidney failure with an indwelling urinary catheter, shortness of breath, history of falling, and stroke was observed sleeping in bed with the catheter drainage bag sitting on the floor without a barrier underneath it, despite the care plan stating the bag should not touch the floor. The Infection Control nurse stated the bag should not be on the floor and needed a barrier under it. The facility further failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. Surveyors observed multiple environmental issues, including an unused spigot near the two-compartment sink, three unused spigots hanging from pipes in the kitchen ceiling, an out-of-order hopper in the main soiled utility room, an out-of-order hair sink in the barber shop, an out-of-order hopper in the 400 unit soiled utility room, and an out-of-order drinking fountain in the dining room. Maintenance staff stated the kitchen spigots had never been turned on and had not been flushed, and chlorine residual was not being tested. The facility’s Water Management Plan required removal or routine flushing of unused piping and monthly disinfectant monitoring, but staff reported these measures were not being performed.
Antibiotic Stewardship Program Not Functioning as Required
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship program that monitored antibiotic use and determined whether antibiotics met criteria for use. Review of the December 2025 infection control data showed separate CAI and HAI line listings, but neither listing specified whether the infections or antibiotics met criteria for use. The monthly infection control summary also did not include information about antibiotic stewardship, appropriateness of antibiotic use, or follow-up for inappropriate antibiotic treatment. During interview, the Infection Control RN stated the facility used McGeer criteria, but the line list did not show whether those criteria were met and the facility had not been tracking antibiotic stewardship data in the monthly summary. Resident #3 had repeated antibiotic exposure and prophylactic antibiotic use without documented risk-versus-benefit review. The resident’s record showed trimethoprim 100 mg daily started for UTI prevention, with no risk-versus-benefit documentation in the medical record. The resident also received multiple antibiotic courses across several months, including cefdinir for UTI, cephalexin for an insect bite, nitrofurantoin followed by ceftriaxone for UTI, clotrimazole vaginal cream for vaginal symptoms, and later trimethoprim prophylaxis with additional antibiotics for UTI. The record also showed trimethoprim given at the same time as cephalexin for UTI, which the RN identified as double antibiotic therapy. The RN stated the facility had no policy about prophylactic antibiotic use or risk versus benefit documentation. Resident #35 also received trimethoprim 100 mg, 0.5 tablet in the evening for prophylactic use without a documented reason or infection and without risk-versus-benefit documentation. Resident #10 was ordered two antibiotics at the same time for UTI, gentamicin injections and nitrofurantoin, before culture results were available. The urine culture later showed no growth, and the antibiotics were discontinued. The record contained no physician progress notes documenting the rationale for the antibiotics, and the Infection Control RN stated the resident should not have been placed on two antibiotics and that culture and sensitivity should have been awaited prior to treatment.
Call Lights Not Kept Within Reach or Answered Timely
Penalty
Summary
The facility failed to ensure resident dignity and timely access to staff by not keeping call lights within reach and by not answering call lights within the timeframes described in its policy. The facility’s call light policy stated residents should have a means of directly contacting caregivers and that unanswered calls should be re-paged at 4 minutes and escalated at 8 minutes. However, survey observations and interviews showed multiple residents with call lights out of reach or hanging on the wall, including a resident with extensive ADL assistance needs, a confused resident who reported call lights took over 30 minutes to be answered, a confused resident in a fall program whose call light was hanging over the bed and could not be located, and a blind resident whose call light was dangling over the bedside table and remained out of reach after the CNA left the room. Resident council and group meeting information also reflected ongoing concerns about delayed response times. Resident council minutes noted call light wait time was too long, and during a confidential resident group meeting, two residents stated staff did not answer call lights timely, reporting waits of 45 minutes on days and nights and saying there were not enough staff. One resident stated an accident occurred because no one came to answer the light and that the resident was mad. The facility’s October call light response records showed 46 instances where call lights were not answered for over an hour, 294 instances over 20 minutes, and 124 instances between 30 minutes and an hour, including one room call light answered in 8 hours and 22 seconds. The report also documented residents not being treated in a dignified manner during observations. One totally dependent resident was observed seated in an activity room facing a blank wall with no call device within reach and no staff present, while staff passed the doorway without checking on the resident. Another resident was later observed seated in a wheelchair in the room with the call light in reach. The facility’s abuse, neglect, exploitation, and misappropriation policy defined neglect to include failure to provide services necessary to avoid physical harm, pain, mental anguish, or emotional distress, including call light availability and prompt answering time.
Insufficient staffing and delayed call light response
Penalty
Summary
The facility failed to provide sufficient staffing to meet resident needs in a timely manner in the Little House unit and for one resident who reported delayed call light response. Survey findings documented repeated call light delays, including multiple calls lasting more than 15 minutes and one call lasting over an hour. Review of call light logs also showed 46 instances in October 2025 when resident call lights were not answered for over an hour, and one room call light on 10/8/25 was answered after 8 hours and 22 seconds. In the Little House unit, surveyors observed that residents were waiting for lunch while dietary staff stated they only delivered trays from the main kitchen and did not distribute them. A CNA was the only staff member present in the unit at that time and was preparing beverages, checking food temperatures, microwaving plates, and serving meals. The CNA stated the nurse was in the main building and that the CNA was the only staff member in the Little House. The CNA also stated that the unit did not have dedicated kitchen staff seven days a week and that they were responsible for preparing resident trays on days when no kitchen staff was assigned. Additional interviews and observations showed that the Little House had only one CNA and one nurse assigned, with the nurse also covering a hall in the main building and coming to the Little House mainly to pass medications. Staff stated they were responsible for all ADL care, activities, call lights, and showers, and that they often could not answer call lights promptly when assisting another resident. One CNA reported there was no staff to cover breaks and that they sometimes had only a walkie for assistance, which did not always work. The DON stated the Little House and main building shared nurse coverage and that all seven residents in the Little House required one-assist care, including one resident who used a sit-to-stand lift. For the resident who complained, the record showed diagnoses including CAD, HTN, PVD, renal insufficiency, obstructive uropathy, DM, depression, and COPD, with substantial to maximal assistance needed for toileting and bathing/showering. The resident stated call lights took too long and that there was only one aide on the hallway during afternoon and night shifts.
Incomplete discharge documentation and communication
Penalty
Summary
The facility failed to ensure that discharge documentation and communication of information to the receiving health care facility were complete in the EMR for one resident who was discharged from the facility on 11/28/25. Resident #52 was admitted with diagnoses including surgical site infection, right-sided hemiplegia and hemiparalysis following cerebral infarction, and a history of kidney transplant. The MDS assessment dated [DATE] showed the resident was moderately cognitively impaired and required supervision to moderate assistance for hygiene and transferring. Review of the EMR found no assessment documentation related to the resident’s transfer and/or discharge on 11/28/25. Progress notes showed the resident had ongoing issues with the right hip incision, including bloody drainage, redness, warmth, and saturation of the dressing. On 11/28/25, the spouse came to the facility and stated they were taking the resident to another hospital because they felt the local hospital did not do the surgery correctly; the nurse documented that the provider approved the discharge and the supervisor was notified. During interviews, RN A confirmed that an assessment should have been completed but was not found in the EMR. The DON and Administrator were unable to provide documentation showing what information was sent with the resident or any follow-up communication related to the discharge or transfer.
Failure to Complete Annual PASARR Review
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure PASARR completion for one resident, resulting in a lack of annual evaluation completion and the potential for lack of comprehensive assessment and care coordination. Resident #8 was originally admitted with diagnoses including dementia, anxiety, depression, psychosis, and adult personality and behavior disorder. The resident's MDS showed severe cognitive impairment and the need for substantial to moderate assistance with ADLs, except eating, and the EMR showed the resident was receiving antianxiety, antidepression, and atypical antipsychotic medications. Record review showed PASARR Level I and Level II screenings were completed by the hospital prior to admission on 6/17/24. During interview, the Social Services Director reviewed the EMR and provided those initial PASARR assessments, then stated the DON does PASARRs now and that they were behind on them, adding that they were thought to be annual. The Administrator also stated PASARR assessments should be completed annually and acknowledged the facility had a change in staff, knew the assessments were behind, and that the DON was receiving education related to PASARR form completion. A facility policy or procedure related to PASARR completion was requested but not received by the end of the survey.
Indwelling urinary catheter bag left on floor
Penalty
Summary
Failure to ensure an indwelling urinary catheter care plan was implemented resulted in the catheter drainage bag being on the floor. Resident #1 was admitted and re-admitted to the facility, was his own person, and required extensive assistance from staff for all ADLs. His diagnoses included myocardial infarction, anemia, pneumonia, back pain, malignant neoplasm of kidney, chronic lung and heart failure, acute kidney failure with a urinary catheter in place, shortness of breath, history of falling, and stroke. The urinary catheter care plan dated 12/10/25 stated to ensure the indwelling urinary catheter drainage bag is not touching the floor. During observation on 1/6/26 at 10:54 a.m., the resident was sleeping in bed with his catheter bag sitting on the floor next to his bed with no barrier under it. During interview, the Infection Control nurse stated the urinary catheter bag should not be on the floor and needed a barrier under it.
Failure to Update Care Plan for Heel Injury
Penalty
Summary
The facility failed to update Resident #22’s care plan interventions after changes in condition, including the development of a left heel deep tissue injury and the use of a heel-up device while in bed. The resident had been admitted after surgery for a left leg fracture and cellulitis. During interview, the resident’s family member stated that a pressure ulcer had developed at the facility and that the heel was being dressed every other day. On observation, the surveyor noted a large brown/purple deep tissue injury on the left heel, and the family member stated that a nurse had previously identified the dark spot and placed a heel-up device on the bed to keep the heels off the bed. Record review showed no mention of the heel injury or heel-up device in the resident’s Kardex/care guide, admission assessment, or care plans. The facility’s care planning policy required care plans to be developed and maintained by the interdisciplinary team and revised as resident conditions changed, with changes entered in point-click-care and a new Kardex printed. The DON stated that care plans were initiated based on diagnosis and needs, but the resident’s care plan pages contained no deep tissue injury to the left heel. The DON also stated that a pressure ulcer care plan had been created and then revised after it was thought to have resolved, while the record review presented during the interview showed care plan changes for potential pressure ulcer development, pressure ulcer development, and revision.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to ensure the provision of services, treatment, and assistive devices to maintain vision and hearing abilities for one resident with impaired vision and hearing. The resident had diagnoses including Parkinson’s disease, depression, anxiety, and heart disease, and the care plan identified impaired visual function related to macular degeneration and a communication problem related to hearing deficit. The resident was documented as legally blind and moderately hard of hearing without hearing aids, and the care plan included ensuring glasses and hearing aids were available and working properly. During observation and interview, the resident was sitting in a recliner in the room, was very hard of hearing, did not make eye contact or track movement with the eyes, and stated, “I can’t see.” The resident reported having seen an eye doctor and receiving new glasses that did not help, and stated the hearing aids “don’t work.” The resident also stated they had not seen an audiologist while at the facility and expressed discontentment, saying, “I crocheted and did stuff all my life. Now I can’t do anything.” On a later interview, the resident was not wearing glasses, no glasses were observed in the room, and the resident said they were unsure where the glasses were and had not followed up with the eye doctor after the new glasses did not help. Record review showed limited documentation after earlier notes that the resident used glasses and was legally blind, and that the resident had moderate difficulty hearing without hearing aids. No documentation was found for audiology consultation in the EMR, and staff and leadership were unable to locate additional information about vision or hearing services. The DON stated the resident had a consult for audiology, said consults were sent on 9/30/24 and again in January 2025, and confirmed the resident had not been seen by audiology. The DON also stated the contracted ancillary company did not have an audiologist available, and the Administrator and DON were unaware of that limitation and had not contacted alternative audiology providers.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to ensure monitoring for anticoagulation medication side effects for one resident who was receiving apixaban (Eliquis) 2.5 mg twice daily for atrial fibrillation. Record review showed the resident was cognitively intact and required partial/moderate assistance with toileting and bathing. During interview, the resident confirmed taking an anticoagulant but did not know the medication name. Review of the resident’s EMR, including the HCP orders, MAR, and progress notes, showed no documentation of monitoring for bleeding or other anticoagulation side effects, and the resident did not have a care plan related to anticoagulant therapy. During interview, the DON stated that a side effect monitoring task is initiated on the MAR when a resident takes an anticoagulant medication and confirmed the resident was receiving apixaban. The DON also confirmed that anticoagulant monitoring was not in place in the resident’s EMR and stated the monitoring task was not reordered when the resident was readmitted to the facility. A facility policy related to anticoagulation medication monitoring was requested but not received by the conclusion of the survey.
Food Service Sanitation and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area after surveyors observed multiple sanitation and food safety issues during the kitchen tour. A carton of Lactaid with a discard date of 12/30/25 was found in the walk-in refrigerator. The slicer was visibly soiled with a substance caked to the blade and had accumulating rust, and the Certified Dietary Manager stated it had not been used in 2 years. The mixer was also visibly soiled with a white substance, and the CDM stated it was supposed to be cleaned every time it was used. Crumbs were observed accumulating on top of pans stored under the counter near the 2-compartment sink. Additional observations in the Small House kitchen showed the microwave visibly soiled on the interior walls and ceiling, the inside of the oven visibly soiled with grease, and the toaster visibly soiled with a large number of crumbs at the top and bottom. During food service and tray preparation, [NAME] Q was observed removing one glove and then donning another glove without washing hands, and later removing both gloves and donning gloves again without washing hands. The facility policy stated that kitchenware and food contact surfaces are to be cleaned and sanitized after each use and after each meal, and that hand hygiene is required before putting gloves on and after removing gloves.
Failure to Issue Beneficiary Notice for Hospice Transition
Penalty
Summary
The facility failed to issue a beneficiary notice (ABN/NOMNIC) to a resident who switched to hospice services, resulting in a potential financial hardship. During an interview and record review, it was found that the ABN/NOMNIC forms for the resident were not signed by the resident or their representative. The resident had been admitted to the facility and later transitioned to hospice services while remaining in the facility. However, the necessary forms were not signed or issued at the time of this care level change. The social work designee and another staff member revealed that the forms were not signed due to the family's choice of hospice, and there was no time window to obtain the signatures. Additionally, the facility did not have an ABN/NOMNIC policy in place at the time of the survey, as confirmed by the Nursing Home Administrator. The administrator mentioned that a policy was being developed but would not be ready for two more weeks.
Failure to Update Care Plans and Inadequate Documentation
Penalty
Summary
The facility failed to update care plans for two residents, leading to delayed nursing interventions and inadequate care. Resident #19, who has severe cognitive decline and multiple health issues including a stage II pressure ulcer, did not have an updated care plan to address the pressure ulcer. Despite a physician's order for specific wound care, the care plan lacked any mention of the pressure ulcer or preventive skin management. Communication between nursing and rehabilitation staff was insufficient, as noted by the Rehab Manager, who confirmed the absence of a care plan for the pressure ulcer. Additionally, the facility had discontinued the use of shower sheets, which previously served as a communication tool for reporting abnormal skin conditions, further contributing to the lack of proper wound care. Resident #50, admitted for rehabilitation following hip surgery, experienced delays in receiving assistance for toileting and bathing. The care plan indicated the need for assistance from two staff members for certain activities, but the Kardex only noted assistance from one staff member for bathing. The resident's shower schedule was not clearly documented, and the CNA responsible for showers admitted that the resident had only received three documented showers in 21 days. The discontinuation of paper shower sheets led to inadequate documentation of bathing activities, as progress notes used by CNAs disappeared after 24 hours, resulting in incomplete records of the resident's care.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for a resident who required substantial assistance due to a recent hip surgery. The resident, an elderly female admitted for rehabilitation services following a post-surgical hip repair, was identified as needing maximal assistance for tasks such as toileting, showering, and personal hygiene. The care plan specified that the resident required the assistance of one staff member for bathing, but there was no documentation indicating the preferred method of bathing or the scheduled days for showers. During an interview, a Certified Nurse Assistant (CNA) revealed that the resident was scheduled for showers twice a week, on Tuesdays and Fridays. However, the CNA admitted that due to being pulled to other duties, some showers were missed. The resident had only received three documented showers over a 21-day period, despite being in the facility for rehabilitation. The CNA also noted that the documentation system for recording showers was inadequate, as progress notes disappeared after 24 hours, and the previous paper documentation system had been discontinued.
Failure to Prevent and Timely Identify Pressure Ulcer
Penalty
Summary
The facility failed to prevent and implement preventive measures to avoid a pressure ulcer and failed to timely identify a pressure ulcer for one resident, resulting in a Stage II pressure ulcer on the coccyx. The resident, who had severe cognitive decline and was dependent on staff for all activities of daily living, developed a pressure ulcer that was not identified until it reached Stage II. The wound nurse noted a reddened area a week prior but did not document it, and the necessary preventive measures, such as a pressure reduction cushion, were not in place before the ulcer developed. The facility's documentation and communication regarding the resident's skin condition were inadequate. There was no documentation of a coccyx wound in the skin/wound assessment, and the care plan was not updated to reflect the actual pressure ulcer until much later. The MDS Coordinator acknowledged that the care plan should have been updated earlier. Additionally, there was a lack of communication between nursing and therapy regarding the need for a pressure reduction cushion, which was only documented after the ulcer had developed. The facility also lacked a system for communicating abnormal skin areas observed during showers, as shower sheets had been discontinued without a replacement method for reporting skin concerns. This contributed to the delay in identifying the pressure ulcer. Despite a nurse's education session on pressure ulcer prevention, the facility did not provide a pressure ulcer preventive policy when requested during the survey.
Inadequate Supervision and Fall Prevention for Residents
Penalty
Summary
The facility failed to maintain adequate supervision for two residents, resulting in repeated falls and injuries. Resident #37, an elderly male with multiple medical conditions including dementia and anxiety, experienced several falls between August and November 2024. These incidents were attributed to factors such as confusion, impaired memory, and poor safety awareness. On one occasion, Resident #37 sustained a head injury and was transferred to the emergency room. The facility's fall prevention policy was not effectively implemented, as evidenced by the lack of continuous neurological assessments following the head injury. Resident #19, who has severe cognitive decline and multiple health issues, also experienced recurrent falls. The resident was prescribed Ativan for anxiety, which was administered regularly and as needed, potentially contributing to the falls. Despite the resident's history of falls and the risks associated with the medication, the facility did not adequately reassess or adjust the medication regimen. The facility's fall prevention policy required comprehensive fall investigations and care plan interventions, which were not sufficiently executed in this case. The facility's failure to adhere to its fall prevention and follow-up policies resulted in inadequate supervision and management of fall risks for both residents. The lack of timely medication review and adjustment, as well as insufficient monitoring and intervention, contributed to the residents' repeated falls and injuries. These deficiencies highlight the need for a more systematic approach to fall prevention and resident safety management.
Failure to Ensure Consent and Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents remained free from unnecessary medications and did not obtain consent for antidepressant use. One resident received Ativan as needed without a stop date, and another resident received antidepressant medications without consent. The facility's policy required informed consent for antipsychotic medications and evaluation of newly prescribed psychotropic medications within 14 days, which was not adhered to in these cases. Resident #19, who had severe cognitive decline and resided in a locked dementia unit, was prescribed Ativan regularly and as needed, resulting in a total potential daily dose of 3.5 mg. Despite the facility's policy, there was no documentation justifying the continuation of the PRN Ativan order. Additionally, Resident #26 was administered Prozac and Trazadone without obtaining written consent until after the medications were started, contrary to the facility's policy requiring consent before administration.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policies and procedures for medication labeling and storage, as observed in three medication carts. During an observation and interview with an LPN, it was noted that probiotics were pre-set in a medication dose cup without a label, indicating a deviation from proper medication storage practices. Additionally, multiple medications were found opened without any indication of the date they were opened or their expiration dates. This included various medications such as Breo Ellipta inhalers, Fluticasone propionate nasal sprays, and Albuterol sulfate vials, among others, for several residents. The lack of proper labeling could lead to the administration of ineffective medications. Further observations revealed unsanitary conditions in the medication carts, with paper debris and loose tablets found in the drawers. The facility's policy mandates that medication carts be kept clean and free of clutter, which was not adhered to. The facility's medication storage policy and pharmacy services guidelines require that medications with shortened expiration dates be labeled with the date they were opened, which was not followed. Additionally, there were inconsistencies in the medication refrigerator temperature logs, with missing logs and logs lacking location details, further indicating lapses in medication management practices.
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What surveyors actually found near you
We read the 15 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tawas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Tawas City | 0.5 mi | ★★★★★ | 15 | 0 |
| Lakeview Manor Healthcare Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Sterling | 27.3 mi | ★★★★★ | 6 | 0 |
| Jamieson Nursing Home | 28.1 mi | ★★★★★ | 12 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 29.1 mi | ★★★★★ | 13 | 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.