Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lapeer County Medical Care Facility during CMS and state inspections, most recent first.
Bilateral Heel Pressure Ulcers: A resident with severe cognitive impairment and total ADL dependence developed two unstageable heel pressure injuries. The resident was observed propelling a wheelchair with heels slightly dragging on the floor and no foot pedals, while the chart showed ongoing bilateral heel wounds and heel-protection interventions that were later discontinued when the resident rubbed heels inside the boots. The DON noted recent influenza, bedrest, decreased intake, and that the resident sometimes used the heels to help propel the wheelchair.
Food service sanitation and handling practices were not maintained in several kitchen and pantry areas. A visibly soiled can opener, mixer, microwaves, cup, and dust-covered fan were observed, along with a leaking hand sink and a chemical feed downstream of an AVB in the dishwashing area. Expired or undated food items were found in refrigerators, and a sanitizer bucket tested at zero despite the facility’s stated concentration and replacement expectations. At the tray line, a staff member touched their face with a bare hand and then continued handling clean utensils for food service.
Dead end plumbing and improper backflow prevention were observed in multiple areas of the facility. A dead end water line remained in the one east pod kitchen after an old juice machine was removed, and another dead end line was found near the hand sink in the soiled utility room on two west. Outside spigots in several courtyards and at the front entrance also had spray nozzles downstream of hose bib vacuum breakers.
Failure to follow care-planned interventions, provide supervision, and ensure safe hot liquid service led to multiple safety issues. A resident with dystonia and dementia was observed repeatedly using a wheelchair without the ordered armrest padding despite a history of bruising, another cognitively impaired resident became stuck in a wheelchair in another resident’s room while staff nearby did not notice, and a resident received hot liquid without a shirt or lap protector and developed blisters.
Delayed assistance and poor dining supervision: During lunch observation, multiple residents sat without help while meals remained uncovered and untouched, and at one point no staff were present in the dining room to monitor or assist them. A resident with hemiplegia, hypertensive heart disease, and CKD reported that call lights were answered slowly, an aide left before completing toileting care, and the resident soiled her pants while waiting; the DON confirmed the call light was left unanswered and the log showed prolonged wait times.
Failure to develop a comprehensive care plan for a resident who smoked and kept a lighter in his room. The resident had COPD, nicotine dependence, and used a motorized wheelchair; he told surveyors he smoked off campus and kept his lighter on his dresser. The care plan addressed smoking education and off-campus smoking, but did not identify where cigarettes or the lighter were to be stored, and the facility policy did not address safe storage of smoking materials.
Inaccurate Psychotropic Medication Care Plan: A resident with dementia, depression, anxiety, and CKD had psychotropic meds including Remeron and Seroquel, but the care plan was not updated to reflect the new Seroquel order and remained unchanged despite a prior dose change. The SW stated psychotropic care plans are updated quarterly and as needed for med changes, and the DON acknowledged the care plan should have included the new medication.
A resident with severe cognitive impairment and allergies to codeine and sulfa antibiotics was given Norco intended for another resident. The MAR did not document the medication administered, and the record showed delayed POA and PA notification. Monitoring documentation included allergic reaction checks but did not assess narcotic effects such as lethargy, and the DON stated the medication should have been documented and the PA notification was not timely.
Enteral Feeding Formula Not Specified in Orders: A resident with a G-tube, dysphagia, and a history of TBI had enteral feeding orders, MAR/TAR entries, Kardex, and care plan documentation that listed only the formula strength and volume, but did not identify the specific brand or type of formula. Staff later retrieved Jevity 1.5 from a cupboard and stated that was what the resident received, while also noting another brand was available and that prior shortages had led to substitutions without the order being updated.
A resident with CHF, dementia, and heart arrhythmia had an oxygen order for 3 L/min via NC with humidification, but the care plan still reflected 2 L at bedtime and when napping. Staff observed the resident anxious, crying, and SOB with an oxygen tank in the red zone and later an empty tank, with O2 sats as low as 79% and 80%; the resident’s NC was also found off and resting on the lap, and a nurse reported the resident removed the oxygen three times during lunch.
A resident with Alzheimer’s disease, dementia, anxiety disorder, and mood disorder was observed propelling her wheelchair rapidly through the unit, entering multiple residents’ rooms, and touching or moving other residents’ belongings and food items. Staff were present but did not redirect her or provide the busy apron, activity blankets, or other tactile items identified in her care plan, and behavior monitoring did not document the room-entering behavior.
Failure to supervise two residents during meals: one resident with MS, hemiplegia, AD, and dysphagia and another resident with AD, DM, dementia, and dysphagia were observed eating in the dining area without consistent staff monitoring or assistance. Staff repeatedly left the area after delivering trays, and the resident with severe cognitive impairment was left without close supervision despite meal ticket instructions for close supervision, encouragement, small bites/sips, and alternating solids and liquids. The resident with moderate cognitive impairment was also not monitored for safe swallowing or prompted to alternate bites and sips as directed.
The facility failed to ensure timely response to call lights and their accessibility, leading to prolonged wait times and unmet care needs for residents. Multiple residents reported waiting for extended periods, sometimes up to several hours, for assistance, resulting in incidents of incontinence and discomfort. Observations revealed call lights were often out of reach, and staff sometimes turned them off without returning to help. These issues were compounded by staff shortages and inadequate monitoring systems.
The facility failed to update care plans for several residents, resulting in deficiencies in pain management, wound care, and psychotropic medication management. A resident experienced severe pain due to an outdated pain management plan, while another's advanced directives were not reviewed as required. Additionally, a resident's psychotropic medication care plan was not updated to reflect recent changes, highlighting a lack of communication among the care team.
A facility failed to provide adequate supervision and fall prevention for residents on a locked Dementia Unit, resulting in multiple falls and injuries. Residents with severe cognitive impairments experienced falls without a nurse present, particularly during night shifts. The call light system was not functioning, and the fall prevention program lacked effective interventions for residents who walked independently. Staffing was insufficient, with no nurse specifically assigned to the unit at night.
The facility's call light system was frequently non-functional, leading to extended response times and unmet needs for residents. Staff reported issues with call light tablets crashing and displaying errors, forcing reliance on a central computer. Residents experienced significant delays in receiving assistance, with some waiting up to an hour or more for help. Observations confirmed multiple instances of non-functioning call light tablets, contributing to the deficiency.
A facility failed to update a resident's DNR status in their care plan, despite the resident having moderate cognitive impairment and multiple diagnoses. The last update was in 2023, and no documentation was found to confirm that the advance directives were reviewed with the family or DPOA, contrary to the facility's policy requiring quarterly reviews.
A facility failed to implement and update a comprehensive care plan for a resident on psychotherapeutic medication. The resident, with severe cognitive impairment, was prescribed Venlafaxine for depression, but the care plan was not initiated until months later and was not updated when the medication was discontinued. The Unit Manager acknowledged the oversight, which was contrary to the facility's policy requiring timely care plan development by the Interdisciplinary Team.
The facility failed to provide adequate nail care for two residents, leading to deficiencies in personal hygiene and potential injury risk. One resident with quadriplegia had long nails and chipped polish, expressing dissatisfaction with inconsistent nail care. Another resident with cerebral palsy had long, jagged nails and facial scratches, likely due to involuntary movements. The facility's policy requires nail care on bath days and as needed, but there was no documentation of care being refused or provided, indicating a lapse in policy adherence.
A facility failed to coordinate hospice services for a resident with multiple health issues, including dementia and fractures. The hospice care plan was delayed, and hospice notes were missing from the resident's medical record. The resident was unsure about receiving hospice services, and the facility's policy on hospice care coordination was not followed.
A resident with Squamous Cell Carcinoma experienced extreme pain due to inadequate pain management. Despite verbal complaints and visible discomfort, the resident's care plan was not updated, and pain relief was not administered. The facility failed to revise the care plan to address the resident's current pain management needs, leading to ongoing discomfort.
The facility failed to complete yearly performance evaluations and competencies for two nurses and two CNAs. The last competencies for the nurses were over a year old. The Staff Education Nurse admitted that performance reviews were not conducted, and there was no process for staff to provide input on training needs. The facility's assessment and job descriptions required participation in training, but these were not followed.
A resident did not receive timely medication due to a delay in coordination between the facility, pharmacy, and dialysis center, resulting in the unavailability of Renvela. Additionally, Cholestyramine was administered incorrectly with other medications, contrary to professional standards. The DON confirmed the delay and improper administration, highlighting deficiencies in medication management.
A resident with severe cognitive loss and multiple wounds was observed receiving wound care without proper PPE by the attending nurse and a nurse aide, despite being under Enhanced Barrier Precautions. The facility failed to use signs indicating the precautions, leading to inconsistent implementation of PPE usage.
The facility failed to provide adequate warm water and proper sink drainage in the rooms of three residents, affecting their ability to maintain personal hygiene. CNAs reported that the sinks did not produce hot enough water, and the drainage was poor, causing the sinks to fill up quickly. Maintenance staff acknowledged the issue and planned to call a plumber, but the deficiency remained unresolved at the time of the survey.
A resident with chronic conditions fell in a facility van due to improper restraint use. The resident was asked to sit on a rolling walker during transport, resulting in a fall when the van made a sharp turn. The driver did not stop to assess the resident or notify the facility, and the resident was only assessed upon returning to their room. The facility's policy requires immediate reporting and assessment of incidents, which was not followed.
Bilateral Heel Pressure Ulcers
Penalty
Summary
Failure to provide appropriate pressure ulcer care resulted in two unstageable heel pressure ulcers for Resident #164, a resident with neurocognitive disorder with Lewy bodies, Alzheimer's disease, psychotic disorder, severely impaired cognition, and dependence for all ADLs. The resident was observed propelling a wheelchair in the hallway with no wheelchair pedals, and the heels were slightly dragging on the floor while the resident propelled. The resident also wore socks during the observation. The record showed new in-house wounds to both heels identified as unstageable pressure injuries presenting as deep tissue injury, with measurements documented for each heel and ongoing weekly wound measurements showing changes in size over time. The resident's care plan identified bilateral heel pressure ulcers related to pressure and included interventions such as encouraging Prevalon boots in and out of bed, along with weekly treatment documentation. The task list also included a low air loss alternating pressure mattress and holding shoes. The DON stated the resident had influenza, was in bed for about a week, had decreased food and fluid intake, and that boots were used but later discontinued because the resident rubbed her heels inside them. The DON also stated the resident sometimes used her heels to assist in propelling the wheelchair and did not always want to rest in bed to elevate her heels. Nurse M stated the pressure ulcers were avoidable.
Food Service Sanitation, Date Marking, and Hand Hygiene Deficiencies
Penalty
Summary
Food service practices were not maintained in accordance with professional standards in multiple kitchen and pantry areas. During the initial kitchen tour, a visibly soiled can opener was observed, and a mixer was also observed visibly soiled. Interior walls of microwaves were observed visibly soiled in the first-floor pantry room and in the two south pantry room. A brownish residue was observed on the interior of a cup on the clean dish rack in the two south east pod kitchen, and a fan with accumulated dust was blowing directly at the three-compartment sink in one east pod kitchen. A steady stream of water was also observed leaking underneath the hand sink in one west pod kitchen. Food storage and date-marking practices were not followed for several items. Shredded lettuce with a best-by date of 3/29 was observed in the cafeteria refrigerator, cooked mushrooms with a discard date of 3/28 were observed in the one west pod kitchen refrigerator, and milk in a cup with a lid was observed without date marking in the one west dining area refrigerator. The Culinary Supervisor stated that expired food is thrown out, and the chopped lettuce was discarded during the observation. The report also noted that Everwipe Chem-ready sanitizer buckets were tested and one bucket read zero, with a prepared date of 2-16-26 and a use-by date of 3-16-26. The Culinary Supervisor stated the sanitizer buckets should be kept at 150-200 and are supposed to be good for a month, while the facility policy stated sanitizer concentration should be 200-400 ppm or per manufacturer recommendation and tested at least once daily. Additional food service observations included a chemical feed downstream of an atmospheric vacuum breaker in the dishwashing area, with wasting tees observed in and above the sink basin. The report cited State of Michigan cross-connection guidance regarding atmospheric vacuum breakers and chemical feeder backflow prevention. At the tray line, [NAME] C was observed touching their face with a bare hand and then using clean utensils to tray food at the two north non-pod tray line. The report cited the FDA Food Code handwashing requirement after touching the face, and the facility policy required handwashing after touching hair, face, or body.
Dead End Plumbing and Improper Backflow Prevention
Penalty
Summary
The facility failed to eliminate dead end plumbing and ensure appropriate backflow prevention was installed at plumbing fixtures. On 03/31/2026 at 9:48am, a dead end water line was observed in the one east pod kitchen area; Maintenance and Housekeeping Manager D stated the line had fed an old juice machine that had been removed about a month earlier and that the unused water line needed to be removed. On 03/31/2026 at 10:16am, another dead end water line was observed plumbed through the wall near the hand sink in the soiled utility room on two west; Manager D stated she was not sure what the line was used for. The report also documented outside spigots with spray nozzles downstream of hose bib vacuum breakers in the one south west courtyard, west courtyard, east courtyard, and at the front entrance. The report cited CDC guidance on eliminating dead legs and the State of Michigan Cross Connection Manual stating atmospheric vacuum breakers shall not be installed where they will be under continuous pressure for more than 12 hours.
Failure to Follow Care Plans, Supervise Residents, and Safely Serve Hot Liquids
Penalty
Summary
The facility failed to follow care-planned interventions for a resident with dystonia, schizoaffective disorder, and dementia who had severely impaired cognition and required extensive assistance with ADLs. The resident’s care plan noted that the power of attorney reported the resident bruised easily and had increased potential for bruising and skin tears due to dystonia, but no intervention for potential bruising was included in the care plan. The physician orders and Kardex identified arm rolls for the wheelchair arm rests as a supportive device, yet the resident was observed pounding on the wheelchair armrests and, on multiple observations, the wheelchair had no padding on both armrests or had padding on only one side. The facility also failed to ensure supervision for a resident with neurocognitive disorder with Lewy bodies, Alzheimer’s disease, and psychotic disorder who had severely impaired cognition and required assistance with all ADLs. The resident propelled their wheelchair into another resident’s room, became stuck at the foot of the bed, and was unable to move the wheelchair forward or backward. Staff were observed in the hallway and nearby areas, including a nurse near a medication cart and two hospitality aides across the hall, but did not notice the resident was stuck until a hospitality aide later saw the resident and assisted them out of the room. The facility further failed to ensure safety with hot liquids for a resident who had been given hot liquid without a shirt protector or lap protector. The DON reported the resident had not been provided these protective items and was unsure whether all staff had been inserviced. The DON also stated the facility did not conduct audits to monitor compliance. The report states the resident developed blisters from the hot liquid, and the blisters later healed without infection.
Delayed Assistance and Poor Dining Supervision
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner during dining and toileting assistance. During observation of the 1st Floor South dining room, 10 residents were seated for lunch while only two nurse aides were initially passing drinks and assisting with meals. Several residents sat without eating, their food remained uncovered and untouched for more than 10 minutes, and at one point no staff were present in the dining room to observe, monitor, or assist the residents. One staff member was in the kitchen, and later a nurse entered and fed two residents at the same time while other residents’ meals had been sitting out for nearly 30 minutes. Resident #162, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the full right dominant side, hypertensive heart disease, and chronic kidney disease, reported that call lights were answered slowly and that newer aides took a long time to respond. The resident described an incident in which an aide entered the room, attempted to remove the commode bucket, became frustrated, left without completing care, and the resident then soiled her pants while waiting for toileting assistance. The DON acknowledged the incident involved a call light left unanswered after an aide left the room, and the call light log showed the resident’s light was on for 42 minutes and later for 28 minutes on the same day.
Failure to Care Plan Smoking Material Storage
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #56 related to smoking. The resident was admitted with diagnoses including history of stroke with left-sided weakness, traumatic brain injury, COPD, nicotine dependence with withdrawal, anxiety, depression, peripheral vascular disease, and chronic pain syndrome. The MDS showed a BIMS score of 15/15, that he needed some assistance with care, and that he used a motorized wheelchair. The resident told surveyors he smoked and went off the facility property to smoke, used a lighter to light cigarettes, and kept the lighter on top of his bedside dresser in his room. The Administrator stated the facility was a non-smoking campus and that the resident left the campus in his electric wheelchair to smoke, but the facility did not keep his cigarettes for him and did not know if he had a lighter or how he lit cigarettes. Review of the care plans showed entries addressing mood/behavior and COPD related to smoking, with interventions to remind the resident that smoking was off campus and that the facility was non-smoking. However, the care plans did not address the resident carrying cigarettes or a lighter in the building, and did not identify where smoking materials were to be stored. The DON later stated the resident had a lock box in his room and was supposed to use it for the lighter when he was not in his room, but this was not reflected in the care plan. The facility policy stated tobacco products were prohibited in all buildings and on all grounds, except in personal vehicles, and did not address where the resident would safely store cigarettes or a lighter.
Inaccurate Psychotropic Medication Care Plan
Penalty
Summary
The facility failed to revise the care plan for psychotropic medications for one resident, a 90-year-old admitted with diagnoses including dementia, major depressive disorder, anxiety disorder, and chronic kidney disease. The resident had physician orders for Seroquel 25 mg at bedtime dated 2/12/26 and Remeron 15 mg daily with a dose change noted on 6/11/25. A medication regimen review was conducted on 04/01/2026, and record review showed the psychoactive medication care plan had been initiated on 03/13/2024 and last revised on 04/15/2025. The care plan referenced Remeron and noted a gradual dose reduction attempt on 4/7/25, but it did not reference the use of Seroquel. The care plan had not been updated since 04/15/2025. During interview, the Social Worker stated that nurses, social workers, and she could update psychotropic medication care plans and that updates were done quarterly and as needed for gradual dose reductions, dose changes, and medication changes. The Social Worker stated the care plan should have been updated for the Seroquel at minimum. The DON was informed of the issue and stated the care plan should have been updated with the new medication that was added.
Medication Error Not Properly Documented or Timely Reported
Penalty
Summary
The facility failed to ensure professional standards of practice were followed in the assessment, monitoring, documentation, and timely physician notification of a medication error involving Resident 131. The resident was admitted with diagnoses including Alzheimer's disease and dementia, had a BIMS score of 4/15 indicating severely impaired cognition, and had documented allergies to codeine and sulfa antibiotics. During the survey observation, the resident was lying in bed, aroused to a knock, and did not answer questions reliably or engage in conversation. The medical record showed progress notes documenting attempts to contact the resident's POA after the medication error, with the POA reached later and the PA notified afterward. However, the MAR contained no documentation of the medication that had been administered in error. The DON stated the nurse had given Norco 5 mg/325 mg, intended for another resident, and acknowledged that the medication should have been documented if given. The DON also indicated the PA notification was not timely and was unsure whether the practitioner had been notified before the next day at 6:00 PM. Documentation of monitoring for signs and symptoms of allergic reaction was present, but it lacked assessment for effects of the narcotic medication such as lethargy, and the DON stated narcotic side effects should have been monitored as well as allergic reactions.
Enteral Feeding Formula Not Specified in Orders
Penalty
Summary
The facility failed to ensure that the enteral nutrition formula was identified when ordered for one resident with a feeding tube. Resident #23 was admitted with diagnoses including traumatic brain injury, epilepsy, quadriplegia, dysphagia, gastrostomy tube, and hearing loss. The MDS indicated the resident had a memory problem, needed assistance with all care, and received nutrition and fluids through the feeding tube. On observation, the resident was sitting in a Broda chair with a tube feeding pump and syringe in the room, and the pump was not running; the resident was alert but unable to answer questions. A review of the physician orders, MAR/TAR, Kardex, care plan, and nutrition risk assessment showed orders for enteral feeding and water flushes, including a continuous nighttime feeding and a daytime bolus feeding via G-tube. However, none of these records identified the specific type or brand of enteral formula the resident was to receive. The nutrition risk assessment listed tube feeding risks and referenced enteral feeding formula 1.5 cal per cc, but still did not name the specific formula. During interviews, nurses retrieved Jevity 1.5 from a cupboard and stated that it was the formula the resident received, while another box of a different brand was also present nearby. The nurses stated the order only said enteral tube feeding 1.5 and did not specify a brand or therapeutic substitution. The nurse manager stated that Jevity had been in short supply at one point, other brands were bought, and the order had not been changed back. The DON stated she was working with staff to ensure a physician order was in place for the specific enteral nutrition the resident was to receive.
Failure to Maintain Updated Oxygen Orders and Continuous Oxygen Delivery
Penalty
Summary
The facility failed to ensure that oxygen administration and the care plan were updated for Resident #1, who had diagnoses including Congestive Heart Failure, dementia, and heart arrhythmia and required assistance with all Activities of Daily Living. The physician order directed oxygen at 3 liters per minute via nasal cannula with humidification continuously, but the care plan still listed oxygen at 2 liters at bedtime and when napping. During observation, the resident was seen anxious, crying, and short of breath while using oxygen equipment that was not functioning as intended, including a wheelchair-mounted oxygen tank with the dial in the red zone and later an oxygen tank that was empty. The resident’s oxygen saturation was documented at 79% and 80% during one observation, and later at 86% when the nasal cannula was off and resting on the resident’s lap. Staff then placed the resident back on oxygen, and the saturation increased to 92% after the wall unit was turned up to 3 liters. A nurse stated the resident had removed the oxygen three times during lunch, and the DON stated staff put the oxygen on when they noticed it was off and acknowledged that the empty oxygen tank and low saturation should not have happened.
Failure to Redirect Resident Entering Other Rooms and Disrupting Others
Penalty
Summary
The facility failed to operationalize care-planned behavioral interventions for a resident with Alzheimer’s disease, dementia, anxiety disorder, and mood disorder who was observed propelling her wheelchair rapidly up and down the hallway and entering multiple other residents’ rooms. During observations, the resident went in and out of rooms, displaced items on another resident’s meal tray, and took a covered plate from one resident’s room and placed it on the bed in another room. Staff were present in the area but did not intervene, redirect her, or offer the tactile or soft items identified in her care plan. The resident’s record showed she was moderately impaired for cognitive decision-making, dependent for activities of daily living, and used a wheelchair that she propelled manually. Her Kardex directed staff to encourage use of a busy apron when up in the wheelchair and, when she was observed entering other residents’ rooms, to redirect her to her room or the common area, distract her with activity, and offer tactile and soft items to hold. The care plan also documented that she wandered into other rooms and had rare occasions of refusing care related to dementia, psychotic disorder, mood disorder, and anxiety disorder. The behavior monitoring documentation for the dates reviewed did not identify entering other residents’ rooms as a behavior, and entries were marked as no behaviors observed. During interview, Activities staff stated the resident had two activity blankets but they were not out at the time and were stored in a bin. The Unit Manager stated staff should redirect the resident when they notice the behavior and acknowledged the resident should be redirected to activities when available. The facility policy on managing residents with anxiety/aggression stated that if a resident is independently mobile and remains in an anxious state, one-on-one intervention should be provided until the resident calms down and safety is maintained.
Failure to Supervise Residents During Meals
Penalty
Summary
The facility failed to ensure supervision was provided during mealtime for two residents with safe swallow instructions. During a lunchtime observation on the second floor dining area, one resident with multiple sclerosis, left-sided hemiplegia, Alzheimer's disease, and dysphagia was seated in a slightly reclined Broda chair and was observed eating without consistent monitoring. Another resident with Alzheimer's disease, diabetes, dementia, and dysphagia was seated at a table and was repeatedly left without staff present while eating, despite meal ticket instructions for close supervision, encouragement for oral intake, small bites and sips, and alternating solids and liquids. During the meal observation, staff delivered trays and then left the dining area. The resident with severe cognitive impairment did not begin eating until staff later returned and placed a fork in her hand. She was observed with her head down and eyes closed after staff left, and at multiple points there were no staff in the dining area while she continued to eat. Staff intermittently entered the area to remove plates from other residents, ask whether she was hungry or done, or briefly encourage a bite, but they did not remain to supervise her meal or consistently assist with intake. The resident with moderate cognitive impairment was also observed eating without being monitored for safety, and staff did not consistently provide the alternating bites and sips noted on the meal ticket. The resident with severe cognitive impairment had meal ticket instructions for close supervision at meals and encouragement for oral intake, and the resident with moderate cognitive impairment had instructions to sit upright, take small bites, eat slowly, alternate bites and sips 1:1, and report coughing to nursing staff. Facility interviews confirmed that staff should have been present during dining to monitor and assist as needed, and that both residents were on swallow precautions and needed supervision while eating. The resident with severe cognitive impairment also had documented weight loss, with weights decreasing from approximately 125 pounds to 121 pounds and then to 116 pounds.
Delayed Call Light Response and Inaccessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach and responded to in a timely manner for multiple residents, resulting in long wait times and delayed assistance. Several residents reported waiting for extended periods, sometimes up to several hours, for staff to respond to their call lights. This delay in response led to incidents of incontinence, self-transfers, and discomfort among residents. For instance, one resident reported waiting up to three hours for assistance, leading to incontinence and the need to self-transfer to the bathroom. Observations and interviews revealed that call lights were often not accessible to residents, either being placed on the floor or out of reach. In some cases, staff turned off call lights without returning to provide assistance, leaving residents without the help they needed. One resident was found with a call light on the floor, inaccessible, while another had their call light hidden under a pillow, making it difficult to use. These issues were compounded by reports of staff shortages and inadequate systems for monitoring call light alerts, such as the lack of pagers and reliance on screens that were not always functional. The deficiency was further highlighted during a Resident Council Meeting, where multiple residents expressed concerns about the delayed response times and the inaccessibility of call lights. The meeting minutes did not reflect these concerns, indicating a lack of communication and documentation regarding the issue. The facility's failure to address these problems resulted in residents experiencing prolonged discomfort and unmet care needs, as evidenced by the numerous accounts of delayed assistance and inaccessible call lights.
Deficiencies in Care Plan Updates and Management
Penalty
Summary
The facility failed to update and review care plans for several residents, leading to deficiencies in pain management, wound care, and psychotropic medication management. One resident, who was dependent on staff for most activities of daily living, experienced severe pain due to a scalp wound. Despite verbal complaints of extreme pain and visible signs of distress, the resident's pain management care plan had not been updated since March 2024, and no pain relief was administered according to the Medication Administration Record. Additionally, the resident's wound care plan was outdated and did not reflect current treatment orders or the resident's condition. Another resident's care plan for advanced directives had not been reviewed or updated since November 2023, despite the facility's policy requiring quarterly reviews. The resident had moderate cognitive impairment and a Durable Power of Attorney, but there was no documentation of recent discussions with the family or updates to the care plan. The facility's social worker and unit manager were unable to locate any progress notes or care conference notes indicating that the advanced directives had been reviewed since 2023. A third resident had a care plan for psychotropic medications that was not updated to reflect recent changes in medication. The resident, who had severe cognitive impairment, was prescribed new medications for depression, but the care plan still referenced a discontinued medication. The unit manager acknowledged that the care plan should have been updated when the new medications were initiated. This oversight was attributed to a lack of communication and coordination among the interdisciplinary care plan team.
Inadequate Supervision and Fall Prevention on Dementia Unit
Penalty
Summary
The facility failed to provide a safe and monitored environment to prevent falls and injuries for four residents on the locked Dementia Unit. Residents experienced multiple falls, with some sustaining significant bruises. The report highlights that there were instances where no nurse was present on the unit during the falls, particularly during the night shift. The call light system on the Dementia Unit was not functioning properly, further compromising the ability to respond to residents' needs promptly. Resident #21, with a history of Alzheimer's dementia and repeated falls, experienced 11 falls over the past year, with three incidents occurring without a nurse present. Resident #103, also with Alzheimer's disease and severe memory problems, had 13 falls, six of which occurred without a nurse on the unit. Resident #126, with severe cognitive loss, had bruising incidents not adequately documented in the care plan. Resident #127, with a history of falls and severe cognitive loss, had multiple falls, including one where she was found on the floor without a nurse present. The facility's fall prevention program, which included measures like orange tags for residents using wheelchairs or walkers, did not effectively prevent falls. The program lacked additional interventions for residents who walked independently. Staffing on the Dementia Unit was insufficient, particularly during the night shift, with only two to three nurse aides covering the unit and no nurse specifically assigned. The Director of Nursing acknowledged the staffing issues but had not planned to assign a nurse specifically to the Dementia Unit during the night shift.
Call Light System Failure Leads to Extended Response Times
Penalty
Summary
The facility failed to maintain a consistently operational call light system, affecting three residents and a resident census of 158. Observations and interviews revealed that the call light tablets, which are crucial for notifying staff of resident needs, were frequently non-functional. Staff reported that the tablets would crash, fail to connect, or display error messages, leading to reliance on a central computer at the nurses' station. This system failure resulted in extended call light response times and unmet resident needs. Resident #46, who has chronic obstructive pulmonary disease, quadriplegia, and other conditions, reported that call lights could take 30 minutes to an hour to be answered. The resident expressed frustration over the lack of timely responses and the absence of pagers or door lights to alert staff. Similarly, Resident #63, with neurocognitive disorder and other health issues, reported long wait times for assistance, sometimes up to four hours, and noted that staff would often turn off the call light without returning. The resident also mentioned instances of not having oxygen during the night due to the delayed response. Resident #74, who has chronic obstructive pulmonary disease and dementia, also reported extended wait times for call light responses, sometimes up to an hour. This resident needed assistance with breathing treatments and inhalers, which were delayed due to the call light system's inefficiency. Observations confirmed that several call light tablets were not functioning, displaying messages such as 'Not responding' or 'Communication Error,' and staff often bypassed these tablets, relying instead on the nurses' station computer or personal phone apps, which were not consistently used by all staff.
Failure to Update Resident's DNR Status
Penalty
Summary
The facility failed to validate and update the care plan for a resident's Do-Not-Resuscitate (DNR) status, which is a critical component of honoring a resident's advance directives. The resident in question, who was admitted with multiple diagnoses including hemiplegia, vascular dementia, and peripheral vascular disease, had a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The resident's advance directives were last updated in November 2023, and the care plan for the DNR status had not been revised since then, despite the facility's policy requiring quarterly reviews. Interviews with the social worker and unit manager revealed that there were no progress notes or care conference notes available to confirm that the resident's advance directives had been reviewed or discussed with the family or the Durable Power of Attorney (DPOA) since 2023. The social worker acknowledged the absence of documentation and noted that sometimes families have difficulty coming in to sign. This lack of documentation and failure to update the care plan for the resident's DNR status represents a deficiency in the facility's adherence to its own policy on advance directives.
Failure to Implement and Update Care Plan for Psychotherapeutic Medication
Penalty
Summary
The facility failed to complete a comprehensive care plan for a resident who was reviewed for unnecessary medications. The resident, who is severely cognitively impaired, was admitted with diagnoses including dementia, major depressive disorder, dysphagia, and atrial fibrillation. A physician's order for Venlafaxine (Effexor) was issued for the resident's depression, but the care plan for this psychotherapeutic medication was not initiated until nearly three months later, despite the medication being started earlier. Furthermore, the care plan was not updated when the medication was discontinued. During an interview, the Unit Manager acknowledged that the responsibility for implementing and updating care plans typically falls to social work, but can also be handled by the MDS nurse or the Unit Manager if necessary. The Unit Manager confirmed that the care plan should have been initiated when the medication was first prescribed and updated with any changes, but this was missed. The facility's policy requires that care plans be developed on a timely basis by the Interdisciplinary Team, but this process was not followed in this instance.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, leading to deficiencies in their personal hygiene and potential risk for injury. Resident #46, who has chronic obstructive pulmonary disease, quadriplegia, heart disease, and contracture of an unspecified joint, was observed with long fingernails and chipped nail polish. Despite being dependent on staff for activities of daily living, the resident expressed dissatisfaction with the length of her nails and indicated that staff did not consistently offer nail care during showers as expected. Resident #78, diagnosed with cerebral palsy, aphasia, severe intellectual disabilities, and abnormal involuntary movements, was also found with long and jagged nails. This resident, who is severely cognitively impaired and dependent on staff for daily activities, was observed with scratches on his face, likely due to his involuntary movements and long nails. The facility's policy requires nail care on bath days and as needed, but there was no documentation of nail care being refused or provided for these residents, indicating a lapse in following the care plan and facility policy.
Failure to Coordinate Hospice Services for Resident
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for a resident who was admitted with hospice care. The resident, who had a history of seizures, falls with fractures, dementia, anxiety, depression, and hypertension, was admitted to the facility with hospice services. However, the hospice care plan was not initiated until nearly two weeks after admission. During an observation, the resident expressed uncertainty about receiving hospice services, indicating a lack of communication and coordination. Further investigation revealed that hospice notes were missing from the resident's electronic medical record and were not readily available at the facility. A hospice binder was eventually located, but it contained only two notes, one from a nurse and one from a social worker, both dated shortly after admission. The Unit Manager confirmed the absence of additional hospice notes and acknowledged the lack of documentation in the resident's chart. The facility's policy required coordination with hospice staff and documentation of hospice care, which was not adhered to in this case.
Inadequate Pain Management for Resident with Carcinoma
Penalty
Summary
The facility failed to provide adequate pain management for a resident diagnosed with Squamous Cell Carcinoma of the skin on the scalp and neck, among other conditions. The resident, who has moderate cognitive impairment, was observed in extreme pain, with a pain scale level of 10 out of 10, and was found grimacing and moaning. Despite these observations, the resident's care plan for pain management had not been updated since March 2024, and the Medication Administration Record (MAR) showed no pain assessments or administration of PRN Tylenol for pain relief, even though the resident verbally complained of pain. During a wound care observation, the resident continued to express significant pain, rating it as 100 on a scale of 1 to 10, yet the nurse indicated that the resident had not complained of pain earlier in the day. The resident's care plan lacked updates to reflect the current pain management needs and did not include interventions to manage pain during wound care. Additionally, the resident's wound/skin care plan had not been revised to address new skin lesions and blood stains observed on the resident's linens. The facility's policy requires that care plans be developed and updated by an interdisciplinary team, but the resident's care plan did not reflect recent changes in the resident's condition or treatment needs. The lack of timely updates and appropriate pain management interventions contributed to the resident's ongoing discomfort and inadequate care, as evidenced by the observations and interviews conducted during the survey.
Failure to Complete Yearly Performance Evaluations and Competencies
Penalty
Summary
The facility failed to ensure that clinical staff, including nurses and nurse aides, received completed yearly performance evaluations and competencies. Specifically, the performance reviews for two nurses, identified as N and O, and two nurse aides, identified as L and M, were not completed. The last recorded competencies for Nurse N and Nurse O were over a year old, dated January 2024. During an interview, the Staff Education Nurse, identified as Nurse C, admitted that the facility did not complete performance reviews to determine staff training and competency needs. Although there was discussion about completing these reviews, they had not been executed. Nurse C also mentioned that the online training program was used to select competencies, but there was no process for clinical staff to provide input on their specific training needs. The facility's assessment indicated that all staff should receive competencies reflecting their work, policies, and procedures. However, the Director of Nursing stated that the policy for staff education was outlined in the employees' job descriptions. The job descriptions for the Team Charge/Charge Nurse, LPN, and CNA all required participation in scheduled training and education classes. Despite these requirements, the facility did not adhere to its own policies, as evidenced by the lack of completed performance evaluations and competencies for the identified staff members.
Medication Management Deficiency
Penalty
Summary
The facility failed to ensure timely delivery and proper administration of medications for a resident, leading to deficiencies in medication management. Specifically, Resident #358 did not receive the medications Renvela and Cholestyramine as ordered. Renvela, used to control phosphorus levels in patients with chronic kidney disease on dialysis, was unavailable for an extended period due to a misunderstanding about the responsibility for supplying the medication. The facility was informed by the pharmacy that the dialysis center needed to supply Renvela, but there was a delay in communication and coordination between the facility, the dialysis center, and the pharmacy, resulting in the medication not being administered for several days. Additionally, the medication Cholestyramine, which requires specific timing in relation to other medications for optimal efficacy, was administered incorrectly. The medication was given alongside other medications, contrary to the directions that it should be taken at least one hour before or four to five hours after other oral drugs. This improper administration was observed during a medication pass, and the Unit Manager acknowledged the error, indicating a lack of adherence to professional standards of care. The Director of Nursing confirmed that the medications should have been available sooner and acknowledged the delay in obtaining Renvela. The facility's failure to ensure timely delivery and proper administration of medications resulted in Resident #358 not receiving necessary treatments as prescribed, highlighting deficiencies in the facility's pharmaceutical services and medication management processes.
Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to adhere to Infection Prevention and Control standards during wound care for a resident under Enhanced Barrier Precautions. The resident, who has severe cognitive loss and requires assistance with all care, was observed receiving wound care without the appropriate use of Personal Protective Equipment (PPE) by the attending nurse. The nurse washed her hands and applied gloves but did not wear a gown as required by the Enhanced Barrier Precautions. Additionally, a nurse aide who entered the room to assist also did not wear the appropriate PPE. The resident had multiple wounds on her right foot, including an unstageable pressure ulcer on the heel, which necessitated Enhanced Barrier Precautions as per physician orders. Despite these orders being documented in the Medication Administration Record and initialed by nurses as being followed, the precautions were not consistently implemented. The Infection Prevention and Control Nurse confirmed that the facility did not use signs to indicate Enhanced Barrier Precautions, contributing to the oversight in PPE usage during wound care.
Inadequate Warm Water and Poor Drainage in Resident Rooms
Penalty
Summary
The facility failed to ensure the availability of warm water and adequate sink drainage in the rooms of three residents, leading to environmental concerns. Observations and interviews revealed that the sinks in the rooms of the affected residents did not produce hot enough water for personal hygiene tasks such as washing up. The water would initially be lukewarm and then turn cooler, making it unsuitable for washing. Additionally, the sinks were observed to have poor drainage, filling up quickly and almost overflowing before any warm water could be obtained. This issue was consistent across multiple rooms, as reported by the Certified Nursing Assistants (CNAs) who had to leave the rooms to fetch warm water from other areas, such as the spa room, to assist residents with their hygiene needs. Interviews with the residents confirmed their dissatisfaction with the water temperature and drainage issues. One resident reported that the water was not warm enough to wash up, and another resident confirmed using the bathroom sink despite the inadequate water temperature. Maintenance staff acknowledged the problem, indicating that there were known issues with the hot water supply and drainage in that section of the facility. The maintenance staff planned to call a plumber to address the problem, but at the time of the survey, the deficiency remained unresolved, affecting the residents' ability to maintain personal hygiene comfortably.
Improper Restraint Use in Facility Van Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the proper application of restraints and adherence to policy during the transportation of a resident, leading to an accident. A resident, who is cognitively intact and has a history of chronic pain syndrome, chronic kidney disease, hyperlipidemia, and depression, was transported back to the facility from a medical appointment. During the return trip, the resident was asked to sit on their rolling walker due to a lack of available seats in the van. The van driver made a sharp turn, causing the resident to fall out of the walker and onto the floor of the van. The driver did not stop the vehicle to assess the resident's condition or notify the facility for assistance. Instead, the driver continued to the facility, where they helped the resident into a wheelchair without a nurse's assessment. The resident was later assessed by a nurse upon returning to their room, revealing a bruise on the left cheek and complaints of shoulder pain, which was consistent with a pre-existing condition. The nurse conducted neurological checks and vital signs, which were normal, and administered pain medication. The facility's policy requires that any accident or incident be reported immediately to the charge nurse and that residents not be moved until assessed for injuries. The driver admitted to poor judgment in allowing the resident to sit on the walker without a seatbelt and failing to report the incident. A review of the facility van revealed a bench seat was available, contradicting the driver's claim of no available seating. The driver's employee file showed no prior disciplinary actions, and they were educated on the transport vehicle safety checklist, which mandates that all passengers be buckled.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 198 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lapeer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mclaren Lapeer Region | 0.7 mi | ★★★★★ | 2 | 0 |
| The Orchards At Lapeer | 1.2 mi | ★★★★★ | 30 | 0 |
| Stonegate Health Campus | 1.3 mi | ★★★★★ | 9 | 0 |
| Briarwood Nursing And Rehabilitation | 15.4 mi | ★★★★★ | 7 | 0 |
| Medilodge Of Grand Blanc | 16.2 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.