Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Mclaren Lapeer Region during CMS and state inspections, most recent first.
Food service safety standards were not followed when kitchen equipment and staff practices were observed. Three spray nozzles were seen downstream of atmospheric vacuum breakers at the dishwasher station, and dietary staff were observed handling gloves improperly on the tray line, including putting on gloves without handwashing, changing gloves without washing hands, and wearing two pairs of gloves at once. The CDM stated one staff member wore double gloves because utensils were too hot.
Failure to assess and change bandages for two residents. Two residents had old or undated dressings left in place without physician orders to assess or change them. One resident had a right elbow skin tear with an undated band aid that appeared old, and the other had an undated pressure dressing on the right arm plus a dated band aid on the left forearm that remained untouched until removed and found to cover dry scabbed areas. Both residents required ADL assistance, and one had a slight cognitive deficit while the other had intact cognition.
The facility did not hold Quality Assessment and Process Improvement (QAPI) meetings quarterly, as required. The DON, who began in June 2024, found no records of meetings prior to May and June 2024, suggesting the committee may not have met quarterly over the past year. This failure resulted in a lack of identification and correction of facility concerns.
The facility failed to assess and monitor bed rails for potential entrapment risks, affecting multiple residents. Observations revealed that side rails had large openings, and assessments were based on visual checks rather than precise measurements. Residents were moved to new rooms with different beds without updated assessments or care plans, contrary to the facility's policy requiring risk assessments for entrapment.
The facility failed to accommodate the needs of three residents, leading to discomfort and inadequate rest. Two residents experienced cold room temperatures, affecting their sleep and comfort. Another resident faced issues with a disruptive roommate, impacting her rest and recovery. Additionally, a resident requested a wider bed due to safety concerns, but no adjustments were made. These deficiencies highlight the facility's failure to address residents' needs and preferences.
Two residents in a LTC facility experienced falls due to inadequate supervision and incomplete investigations. One resident, with a history of traumatic brain injury, fell in the bathroom, resulting in rib fractures. The incident report lacked essential details, and the investigation did not rule out abuse or neglect. Another resident fell shortly after admission due to insufficient supervision, with no proper investigation conducted. The facility failed to provide comprehensive incident reports or investigation summaries, raising concerns about resident safety.
A medication cart was found unattended and unlocked in a hallway, exposing medications and resident information. Additionally, outdated and potentially contaminated supplies were discovered in the medication room, indicating improper storage practices. The facility's staff confirmed that therapy equipment was not meant to be stored there.
The facility failed to follow infection control standards, including hand hygiene and PPE use during wound care, lacked a specific water management plan for the TCU, and did not obtain vaccination consent for a resident. A nurse did not change gloves or sanitize hands during treatment, and the water management plan did not address the TCU's needs. Additionally, vaccination consent was not obtained for a resident unable to consent.
Food Handling and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety. During the initial kitchen tour, three separate spray nozzles were observed downstream of atmospheric vacuum breakers at the dishwasher station. The report also cites the 2008 Cross Connection Manual stating that atmospheric vacuum breakers shall not be installed where they will be under continuous pressure for more than 12 hours, and the 2022 Food Code requiring backflow prevention at each point of use in a food establishment. During lunch observation, Dietary Staff C was observed reaching into a pocket for a pen while wearing gloves, then putting on an additional pair of gloves without washing hands. The same staff member was later observed removing one pair of gloves after stepping away from the tray line and then donning another pair of gloves without washing hands, and was observed wearing two pairs of gloves at the same time. Dietary Staff D was also observed on the tray line removing gloves and putting on gloves without washing hands. The Certified Dietary Manager stated that Dietary Staff C wears two pairs of gloves because the utensils get too hot. The facility policy on sanitation and infection control states that food-handling associates shall wash hands before putting on gloves and after any activity that may contaminate the hands.
Failure to Assess and Change Bandages for Two Residents
Penalty
Summary
The facility failed to assess and change bandages for two residents, resulting in old or undated dressings remaining in place without corresponding physician orders. Resident #9 was observed with a large, undated band aid on the right elbow that appeared old. The resident stated they had fallen at home before going to the hospital and then to the LTC unit. Record review showed an admission with diagnoses including generalized weakness, gastrointestinal bleeding, and chronic kidney disease. The resident required assistance with ADLs and had a slight cognitive deficit. The skin care plan identified a skin tear to the right lower arm, but there was no physician order to assess the skin or change the bandage. When the band aid was removed, the area was found to be a dried, scabbed area measuring approximately 2 cm by 2 cm, and the band aid was left off because the area appeared healed. Resident #32 was observed with an undated pressure dressing on the right upper arm and a large band aid on the left forearm dated 8-31, both of which remained unchanged on the following day. The resident stated that they had a skin tear from bandage removal while in the hospital and preferred to keep the scabs covered because of a bleeding problem. Record review showed an admission with diagnoses including acute blood loss anemia, generalized muscle weakness, and lymphoplasmacytic lymphoma. The resident required assistance with ADLs and had intact cognition. There were no physician orders to assess or change the bandages to the right upper arm or left forearm at the time of review. When the dressings were removed, the right upper arm had a small dried scab from an IV site, and the left forearm had two dry scabbed areas. A later record review identified a wound care order for foam dressing changes to the left lower forearm skin tear, and the initial nursing assessment documented a left forearm site present on admission.
Failure to Conduct Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Process Improvement (QAPI) meetings were held quarterly, which resulted in the lack of identification of concerns within the facility and the absence of corrective actions and monitoring of issues. During an interview, the Director of Nursing (DON) revealed that the QAPI committee was supposed to meet quarterly. However, she could only provide sign-in sheets for meetings held in May and June 2024. The DON, who started in June 2024, found no meeting minutes or sign-in sheets for the previous year, indicating that the committee may not have met quarterly as required. The facility's policy stated that Quality Assurance Meetings should be held at least quarterly to identify quality-related issues.
Failure to Assess and Monitor Bed Rails for Entrapment Risk
Penalty
Summary
The facility failed to perform necessary assessments and ongoing monitoring of bed rails to identify potential areas of entrapment for all residents, including specific residents identified in the report. The deficiency was observed through a combination of record reviews, interviews, and direct observations. For instance, Resident #65 was observed with upper side rails that had large openings, and the maintenance technician indicated that they only checked the side rails if there was a complaint. The Director of Nursing (DON) and a nurse confirmed that there were no documented measurements of the gaps in the side rails, and assessments were often based on visual estimations rather than precise measurements. Several residents, including Resident #70, were moved to different rooms with new beds, but no new assessments were conducted to evaluate the safety of the side rails in these new settings. The care plans and physician orders for these residents included the use of side rails for bed mobility, but there was no specification or assessment of whether the rails were upper or lower, nor were there any updates to the care plans following room transfers. The DON admitted that the Biomed department did not assess the side rails, and the nurses relied on visual checks rather than precise measurements to determine safety. The facility's policy on the use of assist bars and bed rails emphasized a person-centered approach and required assessments to determine the risk of entrapment. However, the policy was not followed, as evidenced by the lack of documented measurements and assessments for the residents' beds and side rails. The report highlights that the facility's failure to adhere to its policy and perform proper assessments and monitoring posed a risk of entrapment for the residents.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of three residents, resulting in discomfort and inadequate rest. Resident #70 and Resident #120 experienced issues with room temperatures being too cold. Resident #70 was observed wrapped in blankets and a towel due to the cold, which affected his sleep and appetite. Despite complaints, the maintenance staff did not address the temperature issue promptly, as they only kept records of temperature adjustments when requested. Resident #120 also complained about the cold room and was observed similarly wrapped in blankets. Resident #116 faced difficulties due to a disruptive roommate, which affected her ability to rest and recover. She complained about the loud TV and her roommate's behaviors, which required her to use the call light frequently. Despite her requests for a room change to improve her rest and recovery, the admission staff was unaware of her complaints, and no action was taken initially. Resident #120 also requested a wider bed due to feeling unsafe and uncomfortable in the narrow bed, which he feared could worsen his sore. Despite his request, no measurements or adjustments were made to the bed. These deficiencies highlight the facility's failure to address the residents' needs and preferences, impacting their comfort and well-being.
Inadequate Supervision and Investigation of Falls in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for two residents, leading to falls and injuries. Resident #14, who had a history of traumatic brain injury and left-sided impairments, fell in the bathroom while being assisted by a CNA. The incident report was incomplete, lacking essential details such as the date, time, and staff involved. The investigation did not rule out abuse or neglect, and the facility did not provide a comprehensive incident report or investigation summary. Resident #119 experienced a fall shortly after admission, sliding off the toilet due to inadequate supervision. The resident required two-person assistance for transfers, but was left alone in the bathroom. The incident was not properly investigated, with no interviews or data collection conducted. The DON provided only handwritten notes and claimed that further documentation was protected by Quality Assurance, preventing a thorough review of the incident. Both incidents highlight the facility's failure to conduct complete investigations and implement necessary interventions to prevent falls. The lack of detailed incident reports and investigation summaries raises concerns about the facility's ability to ensure resident safety and prevent future accidents.
Medication and Information Security Lapses
Penalty
Summary
The facility failed to ensure proper storage and security of medications and confidential resident information. During an observation, a medication cart was found unattended in the hallway with several drawers open and unlocked, exposing medications and resident information on a computer screen to unauthorized access. Nurse J, upon noticing the situation, secured the cart and closed the computer screen. It was noted that Nurse D had stepped away from the cart, leaving it vulnerable. Additionally, the facility's medication room was found to contain outdated and potentially contaminated supplies. Nurse A identified a cupboard with old occupational therapy equipment, including metal eating utensils and a fingernail brush with hair stuck in it, which had not been used for years. The Occupational Therapist and Therapy Manager confirmed that therapy equipment was not stored in the medication room, indicating a lack of oversight and proper storage practices. The Director of Nursing acknowledged the findings and indicated that the items would be disposed of.
Infection Control and Vaccination Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, specifically in hand hygiene and personal protective equipment (PPE) use, water management, and vaccination consent. During a wound care observation, a registered nurse did not change gloves or perform hand hygiene between steps of the treatment process for a resident, potentially compromising infection control. The nurse acknowledged the oversight, attributing it to being overly focused on the treatment process. The facility's water management program was found lacking as it did not specifically address the Transitional Care Unit (TCU) within the long-term care facility. The Infection Preventionist indicated that the hospital's maintenance department handled Legionella water testing, but the Water Safety and Management Plan did not mention the TCU, despite its vulnerable resident population. The Maintenance Director was unaware of why the TCU was excluded and confirmed that the TCU's Infection Preventionist was not involved in related meetings. Additionally, the facility failed to obtain consent for pneumonia and COVID vaccinations for a resident. The Infection Control Preventionist admitted responsibility for the vaccination program and acknowledged that consent was not obtained for the resident, who was unable to consent personally. The influenza vaccine was not offered as it was not flu season, further indicating lapses in the facility's vaccination protocol.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 205 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.
Illustrative
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) |
|---|---|---|---|---|
| Lapeer County Medical Care Facility | 0.7 mi | ★★★★★ | 15 | 0 |
| The Orchards At Lapeer | 1 mi | ★★★★★ | 30 | 0 |
| Stonegate Health Campus | 1.5 mi | ★★★★★ | 9 | 0 |
| Briarwood Nursing And Rehabilitation | 16.1 mi | ★★★★★ | 7 | 0 |
| Medilodge Of Grand Blanc | 16.8 mi | ★★★★★ | 22 | 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.