Below 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 Meadow Brook Medical Care Facility during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, agitation, and chronic pain was subjected to staff actions that included attempting to tie the resident to a wheelchair with bath blankets and using force to push the resident back down when they tried to rise. Security footage showed two CNAs interacting with the resident in an agitated manner, and the resident had no order or care plan for restraints. The DON confirmed the restraint use was not planned, and an LPN later noted the resident had pain and became calmer when moved to a recliner.
A facility failed to provide adequate supervision during transfers and meals for two residents. One resident with high fall risk and a care plan for one-person assist with a gait belt fell during a bathroom transfer after staff grabbed her pants instead of using the gait belt, resulting in a head contusion and a toe fracture. Another resident with dementia and dysphagia was ordered a pureed diet with supervision during all oral intake, but was observed eating breakfast without staff supervision despite a care plan calling for monitoring for pocketing and visual oversight.
A resident was observed using a pommel cushion in a wheelchair, and staff said it was used to keep her upright and prevent her from leaning forward or falling out of the chair. The EMR lacked a physician order, restraint assessment, medical justification, and consent from the resident's DPOA, and staff confirmed the cushion could not be removed independently and had been discussed as a possible restraint without the required documentation.
Incomplete Care Plan for Resident With High Fall Risk: A resident with DM, HTN, muscle weakness, and gout had high fall risk scores and required assistance for transfers, yet the care plan lacked fall-prevention interventions and was not updated after a fall in which the resident struck the head and reported back pain. The care plan also did not reflect the resident’s current use of a bed instead of a reclining chair, and staff interviews confirmed the transfer/fall plan was not in place until weeks after the incident.
A resident with an indwelling urinary catheter and an order for EBP was observed during therapy sessions in which staff did not use PPE during high-contact care. A PTA assisted with transfers while clothing contacted the resident’s clothing, and a COTA handled the catheter bag and tubing during lower body dressing without gloves. Staff interviews showed inconsistent understanding of EBP requirements, despite posted signage and facility policy calling for gown and glove use during high-contact activities such as dressing and transferring.
The facility failed to provide a dignified dining experience for three residents during meal times. CNAs were observed feeding residents while standing and making noises, which did not align with the facility's policy of treating residents with dignity and respect. The DON confirmed these actions were inappropriate.
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential unmet care needs. One resident lacked care plans for a urinary tract infection and constipation, another for falls, pressure ulcers, and pain management, and a third for pain and specialized tube feeding. The facility's policy requires comprehensive care plans, which were not followed.
Two residents were transported in wheelchairs without footrests, contrary to standard care practices, posing a potential injury risk. A CNA and an RN were observed pushing residents without using footrests, despite their availability. The DON acknowledged this as unacceptable and against standard practice.
The facility did not ensure that the required members of the QAPI committee, including the DON, met at least quarterly as per policy. The DON was absent from two meetings, one due to vacation and the other for an unspecified reason, leading to potential decreased quality of care for all 87 residents.
Staff Used Unapproved Physical Control Measures on a Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent staff-to-resident abuse for one resident with severe cognitive impairment and a history of Alzheimer’s disease, dementia with agitation, anxiety, chronic pain syndrome, and gait and mobility problems. The resident had a BIMS score of 3, indicating severe cognitive impairment. The record also noted the resident had chronic pain from a prior motor vehicle accident, which the facility did not recognize as being unrecognized and uncontrolled at the time of the incident. A facility-reported incident and security camera review showed two CNAs interacting with the resident while the resident was seated in a wheelchair in the dining area. One CNA attempted to tie the resident to the wheelchair using a bath blanket to prevent the resident from rising, and another bath blanket was tucked around the resident’s legs and firmly under the thighs for the same purpose. The second CNA was present during the incident and was observed placing a hand on the resident’s chest and using force to push the resident back into the wheelchair when the resident lifted up, and later placing hands on both shoulders and using force to push the resident down into the wheelchair when the resident stood up. The resident had no order for any type of restraint and was not care planned for restraint use. The DON stated the resident was in the dining room with a CNA and that staff were trying to get the resident to eat a salty snack in hopes the resident would drink water with medications later. The DON also stated the CNAs had received training on restraints and abuse prior to the incident, and that the CNA who placed the blanket around the resident did not view the act as a physical restraint. An LPN later stated the resident tended to become antsy in the wheelchair in the afternoon, that staff had learned the resident may have back and hip pain from a prior motor vehicle collision, and that the resident became calmer when moved to a recliner.
Failure to Supervise Transfers and Mealtimes
Penalty
Summary
The facility failed to provide adequate supervision per the plan of care during functional transfers and mealtimes for two residents. One resident was admitted with diagnoses including diabetes mellitus, hypertension, muscle weakness, and gout, and had a fall risk assessment score of 19, indicating high risk for falls. Her pocket care plan indicated she required one-person assist with a gait belt for transfers, stand-by assistance for room ambulation, and wheelchair use in the hallway with assistance, but her care plan lacked transfer and fall-prevention interventions until 27 days after her fall. During a bathroom transfer, staff assisted the resident with a walker while her wheelchair was positioned next to the bathroom area. The resident took a few steps with slippers on, became tangled in the wheelchair wheel, and fell to the floor, hitting her head on the bathroom door frame/door. Documentation stated she had a contusion to the back of her head and a small bruise to her left elbow, and later imaging showed a fracture of the left third proximal phalanx with valgus alignment. Staff interviews confirmed the resident transferred with one staff member and a gait belt, but the CNA stated she grabbed the resident’s pants instead of using the gait belt because the resident was a "bigger lady." The RN confirmed the care plan for transfer and fall-risk interventions was not in place until after the fall. The facility also failed to provide the ordered supervision during meals for another resident admitted with fracture of the lumbosacral spine and pelvis, dementia, and dysphagia. Speech therapy evaluated the resident after pocketing was observed at breakfast and recommended a pureed diet with supervision during all oral intake, with the resident in a common area and within line of sight of clinical staff. The care plan included supervision during all oral intake and monitoring for pocketing, but the resident was observed eating breakfast in the dining area without staff supervision on two occasions. Staff interviews showed differing expectations about the level of oversight, with one CNA stating the resident only needed staff to keep an eye on her, while the SLP and clinical care coordinator identified supervision as visual contact.
Failure to Obtain Required Assessment, Order, and Consent for Pommel Cushion Use
Penalty
Summary
The facility failed to ensure a restraint assessment, physician's order, risk-related education, consent, and medical justification were in place for the use of a pommel cushion for one resident. The resident was observed sitting in a wheelchair with the pommel cushion in place and stated it prevented her from leaning forward to pick things up from the floor. The resident had an activated DPOA in the EMR, but the record did not contain a physician's order for the pommel cushion, documentation identifying the medical symptom for its use, a restraint assessment, or a consent with the potential risks associated with its use. Staff interviews confirmed the cushion was being used to keep the resident upright and prevent her from falling forward from the wheelchair, and that she could not independently remove it. The OT stated the resident did not have positioning concerns in the wheelchair and that the cushion was implemented to prevent forward falls. The RN reviewing the record said she did not see a restraint assessment, and the CCC acknowledged there had been prior discussion about whether the pommel cushion was a restraint but no restraint assessment was completed. The facility policy stated a physician's order, interdisciplinary assessment, and informed consent were required for a physical restraint, and defined a restraint as equipment attached to or near the resident's body that the individual cannot remove easily and that restricts movement or normal activities.
Incomplete Care Plan for Resident With High Fall Risk
Penalty
Summary
The facility failed to complete and update a comprehensive care plan for one resident, who was admitted with diagnoses including diabetes mellitus, hypertension, muscle weakness, and gout. The resident’s MDS assessment showed dependence for toileting hygiene and supervision or touching assistance for sit-to-stand and toilet transfer. The resident also had fall risk assessments showing a score of 11 on admission and 19 on reentry, both indicating high fall risk. Despite this, the resident’s care plan dated 5/2025 contained interventions related to sleeping in a reclining chair and having a walker and quad cane available, but it lacked any interventions for fall prevention. The resident reported having had a fall, and the incident and accident report documented that staff were assisting the resident to the restroom with a walker when the resident’s foot became tangled in a wheelchair and she fell, striking her head on the bathroom door frame/door and reporting lower back pain rated 7 out of 10. The care plan was not updated to include fall interventions until 27 days after the fall with fracture and head contusion, and it was also not updated to reflect the resident’s current use of a bed instead of a reclining chair. During interviews, an RN stated the resident required one staff member and a gait belt for transfers, and another RN confirmed the resident did not have a care plan for transfer or fall risk interventions until after the fall.
Failure to Use EBP During High-Contact Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were used during high-contact resident care activities for one resident with an indwelling urinary catheter. The resident was admitted with diagnoses including fracture around the right prosthetic knee joint, urinary tract infection, and need for assistance with personal cares. The most recent MDS showed the resident required maximum assistance for lower body dressing and functional transfers. A physician order dated 8/13/25 specified EBP for foley catheter care and appliance replacement, and EBP signage was posted on the resident’s door. During observation of therapy sessions in the resident’s private room, a PTA assisted with transfer training between the wheelchair and the edge of bed while the PTA’s clothing came into direct contact with the resident’s clothing, and the PTA was not wearing PPE. On a separate observation, a COTA assisted with lower body dressing and handled the resident’s catheter bag and tubing without gloves and without PPE for the duration of the session. Interviews with the COTA and CCC showed differing expectations about when PPE was required, with the CCC stating gloves were expected whenever the catheter bag or tubing was handled. The facility policy stated EBP includes gloves and gowns during high-contact resident care activities for residents with indwelling devices such as urinary catheters, and CDC guidance cited dressing and transferring as examples of high-contact activities requiring gown and glove use.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to treat three residents with dignity and respect during meal times, as observed by surveyors. On October 29, 2024, during lunch at the Glacier Hill Cottage, two CNAs were seen assisting residents with their meals in a manner that lacked dignity. CNA B assisted a resident by standing next to them and placing food in their mouth, and then CNA A took over, continuing to stand while quickly feeding the resident. Similarly, CNA B assisted another resident by standing and placing a spoon in their mouth. This approach did not provide a dignified dining experience for the residents. On October 30, 2024, during lunch at the Grass Creek Cottage, CNA C assisted another resident by placing the meal in front of them, sitting down, and wearing gloves throughout the meal. CNA C made clicking noises or hummed while assisting the resident, which was not considered respectful or dignified. The Director of Nursing confirmed that these observations did not align with the facility's policy of treating residents with kindness, dignity, and respect.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in potential unmet individualized care needs. Resident #24 was always incontinent of bowel and bladder and dependent on staff for toileting hygiene. Despite being diagnosed with a urinary tract infection and experiencing constipation, there were no care plans addressing these issues. Resident #83, admitted with multiple pain-related diagnoses and a history of falls, did not have care plans for falls, pressure ulcers, or pain management, despite these areas being triggered for care planning. The RN acknowledged the incomplete care plan, attributing it to the resident's impending transfer to another unit. Resident #86, admitted with metabolic encephalopathy, gastrostomy, and a pressure ulcer, lacked care plans for pain management and specialized tube feeding. The care plan for pressure ulcers was incomplete, with no goals or interventions listed. The Director of Nursing confirmed the expectation for nursing interventions to be included in the care plan. The facility's policy mandates comprehensive, person-centered care plans with measurable objectives and timeframes, which were not adhered to in these cases.
Failure to Use Wheelchair Footrests During Resident Transport
Penalty
Summary
The facility failed to transport two residents safely and according to standards of care, resulting in a potential for injury. On October 29, 2024, a registered nurse (RN) was observed pushing a resident in a wheelchair without footrests from the dining area to the resident's room. The resident had plastic boot-like shoes on both feet, which were barely off the floor during transport. A certified nurse assistant (CNA) intervened and attached the footrests to the wheelchair. The RN acknowledged the oversight, stating that foot pedals should have been used. On October 30, 2024, a CNA was seen pushing another resident in a wheelchair without footrests, despite the footrests being readily available on the back of the wheelchair. The CNA admitted to being new to the area and recognized the mistake of not using the foot pedals. The Director of Nursing (DON) confirmed that transporting residents without footrests is unacceptable and against the standard of practice.
QAPI Committee Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly, as mandated by their policy. The review of the QAPI committee meeting attendance logs revealed that the Director of Nursing (DON) was absent from the meetings held on July 10th and September 11th, 2024. During an interview, the DON explained that their absence in September was due to being on vacation, and they were unsure about the reason for their absence in July. The facility's policy requires the QAPI committee to include the DON, among other members, and to meet quarterly to address quality deficiencies. This failure resulted in the potential for decreased quality of care for all 87 residents in the facility.
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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 Bellaire
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kalkaska Memorial Health Center | 13.3 mi | ★★★★★ | 4 | 1 |
| Grandvue Medical Care Facility | 18.4 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Leelanau | 22.9 mi | ★★★★★ | 11 | 0 |
| Orchard Creek Skilled Nursing | 24.1 mi | ★★★★★ | 14 | 0 |
| Medilodge Of Gtc | 24.4 mi | ★★★★★ | 20 | 1 |
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