Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manistee County Medical Care Facility during CMS and state inspections, most recent first.
Failure to Offer Eligible Pneumococcal Vaccine: A resident with MS, dementia, and failure to thrive was eligible for a pneumococcal vaccine, but the MD chose not to offer it. The EMR and MCIR showed the resident was due for PCV20/PCV21, yet there was no documentation of vaccine education or declination. The DPOA stated she was not offered the vaccine or educated on its purpose, risks, or benefits, and said she would have wanted the resident to receive it.
The facility failed to provide dignified care for five residents, leading to feelings of intimidation and fear. A resident reported that a staff member refused to clean a spill, while another resident experienced inadequate toileting hygiene. The DON acknowledged multiple complaints about staff behavior but lacked documentation. A resident and their family reported disrespectful treatment, including being left on urine-soaked pads. Despite complaints, issues were not adequately addressed, leaving residents uncomfortable.
A resident was found unresponsive and tested positive for cocaine at the hospital. The facility delayed reporting this incident to the state agency, despite being aware of the test results upon the resident's readmission. The DON confirmed the delay in reporting, and the family was informed by the hospital, asserting no history of drug use.
A resident received insulin injections and blood sugar tests from a CNA, which are tasks outside the CNA's scope of practice. The resident's care plan required these tasks to be performed by licensed nursing staff. The incident occurred when an RN assigned these duties to the CNA, acknowledging it was a mistake and documenting the actions as if performed by the RN.
A resident with Type 2 diabetes mellitus was not provided with necessary standards of care, as there were no physician orders for blood glucose monitoring or a Glucagon Emergency Kit, despite daily blood sugar testing. The facility's policy did not include Glucagon use, leading to a deficiency in diabetes management.
A resident with a Stage 4 pressure injury did not receive appropriate care, as the facility failed to provide pressure-reducing support surfaces and accurate documentation. The resident's care plan lacked necessary interventions, and weekly skin assessments were not conducted as required by facility policy. The DON confirmed these deficiencies, highlighting a failure to adhere to the facility's standards of care.
A facility failed to implement interventions for a resident with limited ROM, leading to a deficiency. The resident, with cerebral palsy and other conditions, was observed with her head slumped onto her shoulder, causing neck excoriation. Despite care plans requiring repositioning, staff did not reposition her, and no therapy screening was conducted. The DON confirmed the worsening condition and the need for a therapy screen.
The facility failed to secure medications and biologicals, as the medication room door was repeatedly found propped open and unattended. Unauthorized access was possible, and staff food items were stored in the medication refrigerator alongside resident medications. The DON confirmed these practices were unacceptable and against facility policy.
The facility failed to follow Enhanced Barrier Precautions for two residents with pressure injuries, as a nurse did not wear a gown during dressing changes, despite signage indicating the need for gowns and gloves for high-contact care. The nurse acknowledged the oversight in an interview.
The facility did not complete, post, or retain daily nurse staffing information for 73 out of 92 days, affecting the ability of residents and visitors to know staff availability. The part-time Nursing Administrative Assistant/Scheduler only completed postings on her working days, without delegating the task when absent. The DON expected daily completion as per regulations.
Failure to Offer Eligible Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that one resident was offered an eligible pneumococcal vaccine in accordance with CDC recommendations. The resident was admitted with diagnoses including multiple sclerosis, dementia, and failure to thrive. The electronic medical record showed the resident’s most recent pneumococcal immunization was given on 6/27/17, and the next pneumococcal immunization status was listed as refused. The Michigan Care Improvement Registry showed the recommended date for the PCV20/PCV21 vaccine was 6/27/22, but no education regarding the benefits and risks of the immunization or documentation of declination could be found in the resident’s EMR. During interview, the Infection Preventionist confirmed the resident was eligible for a pneumococcal vaccine but stated the physician chose not to offer it. A progress note documented that the resident’s immunization status was reviewed with the physician and that, although the resident had previously received pneumococcal 23 and Prevnar 13, the physician did not wish to order PCV at that time. The resident’s DPOA stated she was not offered the vaccination, was not educated on its purpose, and was not informed of the risks or benefits, and she indicated she would have wanted the resident to receive it.
Failure to Provide Dignified Care and Services
Penalty
Summary
The facility failed to ensure dignified care and services for five residents, resulting in feelings of intimidation, frustration, and fear of retaliation. Confidential Resident C2, with intact cognition, reported that Staff T refused to clean up a spilled beverage, leaving it on the floor for over an hour. Staff U confirmed the incident and noted awareness of complaints regarding Staff T's treatment of residents. Despite these issues, no disciplinary action was found in Staff T's personnel file. Confidential Resident C4, with moderate cognitive impairment, reported inadequate toileting hygiene by Staff V, which was confirmed by the Director of Nursing (DON) who acknowledged multiple complaints about Staff V's behavior. The DON admitted to receiving numerous complaints daily, some of which were not documented. Despite reassigning Staff V, the DON confirmed a pattern of behavior that made residents uneasy, yet no written documentation of complaints was found in Staff V's personnel file. Confidential Resident C1, with intact cognition, and their family member reported disrespectful treatment by Staff V, including being left on urine-soaked pads and being spoken to in a demeaning manner. C1's family member witnessed Staff V's inappropriate behavior and lack of urgency in addressing C1's needs. Despite complaints to the DON, C1 felt that the issues were not adequately addressed, and Staff V continued to provide care under certain conditions, leaving C1 uncomfortable and staff feeling intimidated.
Failure to Timely Report Positive Drug Test
Penalty
Summary
The facility failed to notify the state agency in a timely manner regarding a reportable occurrence involving a resident who tested positive for cocaine. On September 26, 2024, a resident was found unresponsive in his wheelchair, and subsequent medical evaluation at the emergency department revealed a positive urine drug screen for cocaine. The attending physician confirmed the presence of cocaine metabolites in the resident's system, which could not be explained by the resident's medication list or any known cross-reactions. Despite the serious nature of the findings, the facility did not report the incident to the state agency until October 2, 2024. The delay in reporting was confirmed during an interview with the Director of Nursing, who acknowledged that both she and the Nursing Home Administrator were aware of the positive drug test results upon the resident's readmission to the facility. The family member of the resident was informed of the cocaine presence by the hospital, and they asserted that the resident had no history of illicit drug use. The failure to promptly report the incident to the state agency constitutes a deficiency in the facility's compliance with regulatory requirements for reporting suspected abuse, neglect, or theft.
Unlicensed Staff Administered Insulin and Blood Sugar Tests
Penalty
Summary
The facility failed to ensure that invasive blood sugar testing and insulin injections were administered by licensed nursing staff for a resident, identified as R19. Instead, a Certified Nurse Aide (CNA B) performed these tasks, which are outside the scope of practice for a CNA. R19 reported that CNA B administered two insulin shots on separate occasions, which R19 recognized as inappropriate. The resident's physician orders specified that insulin injections and blood glucose monitoring should be conducted by licensed nursing staff, highlighting a clear deviation from the prescribed care plan. The Director of Nursing (DON) confirmed the incident, noting that it occurred on a weekend and involved RN A assigning the tasks to CNA B. RN A admitted to asking CNA B to perform blood sugar monitoring and insulin administration, acknowledging it was a mistake and that they should have sought assistance from another nurse. Despite knowing it was wrong, RN A documented in the Medication Administration Record (MAR) that they had administered the insulin, further compounding the error. This incident underscores a significant lapse in adhering to the facility's protocols for medication administration.
Deficiency in Diabetes Management for a Resident
Penalty
Summary
The facility failed to provide necessary standards of care for diabetes management for a resident with Type 2 diabetes mellitus, resulting in a potential risk for diabetic-related complications. The resident, who was admitted with severe cognitive impairment, was receiving insulin injections as per the orders documented in their Medication Administration Record (MAR). However, there were no physician orders for blood glucose monitoring, despite the resident's blood sugar being tested three times a day with values ranging from 63 to 334. Additionally, there was no order for a Glucagon Emergency Kit, which is crucial for managing severe hypoglycemia. Interviews with the Registered Nurse and the Director of Nursing confirmed the absence of physician orders for blood glucose monitoring and the lack of a Glucagon order in the facility's standing orders. The facility's Hypoglycemia Management policy did not include the use of Glucagon, which is a standard practice for managing low blood sugar emergencies. This oversight in diabetes management practices highlights a deficiency in the facility's adherence to proper diabetic care protocols.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care for a resident with a pressure injury, resulting in a deficiency. The resident, who was dependent on staff for activities of daily living, including bed mobility and repositioning, was observed sitting in a recliner without a pressure-reducing cushion and had a standard facility mattress on their bed. Despite having a physician's order for treatment of a Stage 4 pressure injury to the sacrum, the wound evaluation forms inconsistently documented the injury as Stage 3, indicating a lack of accurate documentation. Additionally, there were no documented skin assessments for the resident from early September to early October, contrary to the facility's policy requiring weekly assessments. The resident's care plan lacked interventions for pressure-reducing devices for both the bed and chair, and did not document the resident's refusals of position changes or provide alternative interventions to alleviate pressure. The Director of Nursing confirmed the absence of necessary skin assessments and care plan interventions, acknowledging that the resident should have had a therapeutic support surface, such as a low air loss mattress. The facility's policies on skin assessments and standards of care emphasize the need for individualized care plans and consistent quality care, which were not adhered to in this case.
Failure to Implement ROM Interventions for Resident
Penalty
Summary
The facility failed to implement necessary interventions to address the range of motion (ROM) for a resident with limited mobility, resulting in a deficiency. The resident, who has cerebral palsy, epilepsy, anoxic brain damage, and anxiety disorder, was observed with severely impaired cognition and had not received any therapy or restorative nursing program services. Observations revealed that the resident's head was consistently slumped onto her right shoulder, causing excoriation and redness on her neck. Despite the care plan indicating the need for repositioning every two hours, the resident was not repositioned, and no assistive devices were used to support her head. Interviews with staff, including a CNA and the Director of Rehabilitation, confirmed that the resident's head positioning had worsened since admission and that no therapy screening had been conducted. The facility's Standards of Care policy requires repositioning for residents who cannot do so themselves, but this was not followed for the resident in question. The Director of Nursing acknowledged the worsening condition and the need for a therapy screen, highlighting a failure to adhere to the facility's care standards and policies.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all medications and biologicals were stored in locked compartments accessible only by authorized personnel. During an observation, the second-floor medication storage room was found propped open and unattended, allowing unauthorized access. A Registered Nurse (RN) acknowledged that the door should not have been left open and unattended. Additionally, the medication refrigerator, which was unlocked, contained staff food items alongside resident medications requiring refrigeration. The RN removed the food items and closed the medication room door. Later, the medication room door was again found propped open and unsupervised. Unsecured medications, including discarded medication for a resident, were observed in the room. The Director of Nursing (DON) confirmed that the medication room door should not be left open and unattended. The DON also stated that it was unacceptable for staff to store their lunch food items in the medication refrigerator. The facility's policy requires that drugs and biologicals be stored in locked compartments under proper temperature controls, accessible only to authorized personnel.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) and infection control standards for two residents, resulting in a potential risk for the spread of infection. Resident #43 had a stage 3 pressure injury on the sacrum and a stage 2 pressure injury on the right buttock. Despite signage indicating the need for personal protective equipment (PPE) including gowns and gloves for high-contact care, the Wound Nurse (RN M) was observed performing dressing changes without wearing a gown, only using gloves. This was contrary to the EBP instructions posted outside the resident's room. Similarly, Resident #12, who had a stage 3 pressure injury on the right gluteus, was also subject to inadequate infection control practices. The EBP signage outside the resident's room instructed staff to wear gowns and gloves for high-contact care. However, during a dressing change, RN M again failed to wear a gown, only using gloves. In an interview, RN M acknowledged the requirement to wear a gown during high-contact care activities such as wound care but admitted to not following the protocol during the procedures.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to complete, post, and retain the required daily nurse staffing information, affecting the ability of residents and visitors to determine the number of staff available for resident care. This deficiency potentially impacted all 45 residents in the facility. A review of the Daily Nursing Staff sheets from July to September revealed that postings were not completed for 73 out of 92 days. The Nursing Administrative Assistant/Scheduler, who was responsible for this task, worked part-time and only completed the postings on the days she was present. She confirmed that the task was not delegated to another employee on her days off. The Director of Nursing stated that her expectation was for the staffing information to be completed daily, as it is a regulatory requirement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Manistee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Ludington | 22.8 mi | ★★★★★ | 13 | 0 |
| Oakview Medical Care Facility | 23.1 mi | ★★★★★ | 9 | 0 |
| Paul Oliver Memorial Hospital Ltcu | 25.3 mi | ★★★★★ | 0 | 0 |
| Maples Benzie County Medical Care | 26.7 mi | ★★★★★ | 15 | 0 |
| Grand Oaks Nursing Center | 32.9 mi | ★★★★★ | 2 | 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.