Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Medilodge Of Cass City during CMS and state inspections, most recent first.
Provide and implement an infection prevention and control program was deficient because the facility did not have an active and ongoing plan for reducing legionella and other opportunistic pathogens in the plumbing system. Surveyors observed a water softener drain line sitting inside a floor drain, a utility sink with supplies stored in the basin and leaking from the atmospheric vacuum breaker, and a drinking fountain that would not turn on. Staff gave conflicting statements about whether the utility sink was used or flushed weekly, and there were no flushing records. Record review also showed a prior positive legionella result in a utility room, while the Water Management Program required weekly flushing of low-flow pipe runs, dead legs, and infrequently used fixtures.
Missing Diabetic Care Plan: A resident with type 2 DM, dementia, a history of falls, and delusional disorders had an insulin order and an MDS showing DM, but the record contained no diabetic care plan. The DON confirmed the care plan should have been in place and stated it was not in the record.
Failure to monitor and treat constipation: A resident with dementia, MS, dysphasia, weakness, and hospice care had repeated long stretches without a BM, including 8 days with no BM, while staff documented abdominal distention, bloating, and discomfort. The resident had bowel orders for Fleet enemas, PRN Dulcolax, and MOM, but the PRN suppository was not documented as given until a new order was written, and an abd x-ray later showed an ileus pattern and could not rule out obstruction. Staff interviews and the bowel watch list showed the bowel protocol was not escalated until late in the episode, and the DON acknowledged the provider was not contacted until day 8.
Colostomy Care Documentation Missing A resident with severe cognitive impairment and a colostomy had a care plan addressing ostomy care, but the facility did not document routine colostomy changes or assessments of the stoma, surrounding skin, or stool consistency/color. Records showed inconsistent or absent orders across months, and during observation the ostomy bag contained liquid brown stool and the stoma appeared red and not fully visualized. The DON stated the appliance should be changed every 7 days and PRN, while available ostomy supplies were limited to appliances and bags.
Incomplete dialysis communication records and inconsistent access site documentation were found for a resident receiving dialysis. The resident had ESRD, DM, HF, COPD, and HTN, and the chart showed conflicting information about the dialysis access location, with orders referencing an AV shunt and AV fistula in the left upper arm while the communication record listed a right chest CVC. Several dialysis forms were missing pre-dialysis assessment details such as VS, weight, pain, and access site information, and one form was blank on the facility side even though the dialysis center documented a brief unresponsive episode from hypotension.
Medication administration parameters were not followed for two residents. One resident with CHF, dementia, and other chronic conditions received Metoprolol and Hydralazine despite low HR or BP below ordered hold limits, and the chart lacked notes explaining why the meds were not held. Another resident with DM and dementia received Lyumjev insulin multiple times when BS was below the ordered hold parameter; the DON stated nurses should hold insulin unless the physician was notified and approved giving it.
A survey identified significant deficiencies in medication management at a LTC facility, including improper oversight of controlled substances, expired medications, and inaccurate reconciliation of narcotic medications. Discrepancies were found in medication counts and documentation, with staff unable to provide explanations. Additionally, a resident received the wrong form of Oxycodone due to an electronic medical record issue.
The facility failed to properly label, store, and dispose of medications, leading to deficiencies in three medication carts, a medication room, and an unlocked linen closet. Open and undated medications, expired drugs, and accessible medical supplies were found, with staff unable to provide explanations. The facility's policy requires medications to be stored in locked compartments, which was not followed.
A resident in a LTC facility reported undignified treatment by a CNA, who spoke rudely and failed to assist them in a timely manner. The resident's room was uncomfortably hot, lacking air conditioning, which added to their discomfort. Despite the resident's complaints, no incident forms were received by the survey's conclusion.
The facility failed to provide adequate hygiene and environmental care for two residents, resulting in unkempt conditions and foul odors. One resident avoided using their bathroom due to a strong odor, while another had an uncovered bedside commode with dried stool. Both residents required maximum assistance for daily activities, and the facility's policy on maintaining good grooming and hygiene was not followed.
A resident developed a Stage IV coccyx ulcer and two unstageable ankle ulcers due to inadequate repositioning and prolonged wheelchair use. Despite the facility's policy on pressure injury prevention, the resident's wounds were not prevented, leading to delayed healing.
The facility failed to implement effective fall prevention measures for two residents, resulting in multiple falls and inadequate documentation. One resident experienced several falls with repetitive and ineffective interventions, while another resident, who was severely cognitively impaired, was placed in a room far from the nurses' station, contributing to their falls. The Director of Nursing was unable to provide explanations for the deficiencies, highlighting a failure to follow the facility's fall prevention policy.
The facility failed to adhere to care-planned interventions for two residents requiring enteral feeding, leading to potential risks of aspiration and tube malfunction. One resident was often without an abdominal binder and improperly positioned, while another was observed with inadequate head elevation during feeding, despite showing signs of respiratory distress.
The facility failed to provide appropriate respiratory care for three residents using CPAP and oxygen therapy. A resident's CPAP mask was found uncovered, and there was no care plan for its use. Another resident had confusion over the type of water for the CPAP machine. A third resident's oxygen was set incorrectly, contrary to physician orders, and the LPN was unaware of the discrepancy.
A facility was found to have a medication error rate of 12% due to errors involving three residents. An LPN administered an incorrect dose of Valporic Acid, another reconstituted Aztreonam improperly, and a third resident received the wrong form of Oxycodone. The facility failed to provide a medication administration policy upon request.
A facility failed to ensure proper hand hygiene and PPE use during the care of a resident with severe cognitive impairment and multiple medical conditions. A CNA used the same gloves for incontinence care and retrieving items from a pocket, while a nurse donned gloves without hand hygiene and used the same gloves throughout wound care procedures.
Two residents experienced delayed staff response due to a broken call light system in their room. Despite using a handheld bell as an alternative, staff did not respond promptly, leading to frustration and concern. The issue persisted for several days without being addressed on the maintenance list.
Infection Prevention and Control Program Lacked Active Water Management Oversight
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens in the plumbing system. During an environmental tour, the Director of Maintenance observed a drain line to the water softener sitting inside the drain in B hall. Record review showed legionella testing was positive in the C utility room at 0.8 CFU/mL, with a later retest negative for the C utility hall. The facility’s Water Management Program stated that low-flow pipe runs, dead end legs, and infrequently used fixtures were to be flushed weekly. Additional observations and interviews showed inconsistent and undocumented management of plumbing fixtures. In the janitor’s closet between C and D halls, a box of supplies was stacked inside the basin of the utility sink, housekeeping staff stated they did not use the sink, and the sink was observed leaking from the atmospheric vacuum breaker. The Senior Maintenance Director and Director of Maintenance gave conflicting statements about whether the sink was used and who flushed it weekly, and the Senior Maintenance Director stated there were no records of flushing. A drinking fountain between A and B halls would not turn on, and the Nursing Home Administrator stated it was shut off due to an ongoing construction project, but she was unsure when it had been shut off.
Missing Diabetic Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident, R31, out of 16 residents reviewed for comprehensive care plans. R31 was [AGE] years old, admitted to the facility on [DATE], and had diagnoses of type 2 diabetes mellitus, dementia, history of falling, and delusional disorders. The comprehensive MDS dated [DATE] identified diabetes mellitus, and the record also contained an order dated 10/17/24 for Lyumjev insulin 2 units subcutaneously prior to meals, to hold if blood sugar was less than 120 and to call the physician if blood sugar was more than 300. On 08/27/25, record review showed there was no care plan present for R31's diabetic care. During an interview on 08/28/2025, the DON confirmed that R31 should have a care plan in the record for diabetic management and stated, "I'm not sure why there isn't one in the record, I will put it in right now." The facility policy titled Comprehensive Care Plans stated that a comprehensive person-centered care plan is to be developed for each resident and that it will be developed within 7 days after completion of the comprehensive MDS assessment.
Failure to Monitor and Treat Constipation
Penalty
Summary
The facility failed to provide appropriate treatment and monitoring for constipation for a resident with a history of constipation, dementia, generalized weakness, impaired mobility, dysphasia, multiple sclerosis, and hospice care. The resident had repeated stretches without a bowel movement, including one period of 5 days with only small bowel movements and another period of 8 days without a bowel movement. During observation, the resident was seen rubbing his abdomen, stating he could not go, appearing distended, and later an abdominal x-ray was performed that showed an ileus pattern and could not rule out obstruction. Record review showed the resident had standing and PRN bowel-related orders, including daily Fleet enemas during certain periods, a PRN Dulcolax suppository, and Milk of Magnesia every 72 hours if no bowel movement for 3 days. Despite these orders, documentation showed long gaps without bowel movements, and there was no documentation that the PRN Dulcolax suppository had been given during August until a new order was written for 2 suppositories, after which the resident had 2 large bowel movements. Notes also documented bloating, abdominal distention, and that the resident had not had a bowel movement for 7 to 8 days even with enemas. The resident’s care plan identified a history of constipation, but the interventions had not been updated since the prior year despite worsening constipation. Staff interviews indicated the bowel protocol was based on escalating interventions by day count, with provider notification not occurring until day 6, and the DON acknowledged that the resident was on day 8 without a bowel movement and that the nurses did not address the issue with the provider until then. The bowel watch list showed residents were tracked by days without a bowel movement, and staff stated the resident should have received a suppository earlier in the course of the constipation episode.
Colostomy Care Lacked Required Assessments and Documentation
Penalty
Summary
The facility failed to ensure a comprehensive bowel elimination care plan and failed to ensure documented assessments and changes for a resident’s colostomy. Resident #38 had diagnoses including Mild Intellectual Disabilities, Alzheimer’s disease, and Dementia, required assistance with all ADLs, and had severely impaired cognition on the most recent quarterly MDS. The care plan identified an alteration in GI elimination related to the colostomy and included interventions to assist with colostomy care, observe the stoma site for irritation or complications, and empty the colostomy bag as needed. Record review showed the treatment administration record for August 2025 listed the colostomy to be changed when coming off and as needed for bowel movement, but there were no documented colostomy changes. The July and June 2025 treatment records contained no order to change the colostomy or assess the skin, stoma, or stool consistency. Skin assessments and progress notes for multiple dates also lacked documentation of the stoma, surrounding skin, and stool consistency or color. During observation, the resident’s ostomy bag contained liquid brown stool and the stoma appeared red and could not be completely visualized. The DON stated the ostomy should be changed every 7 days and as needed, and a later physician order directed the bag and flange to be changed every 7 days and as needed. When ostomy supplies were observed, only appliances and bags were present, with no stoma wipes, adhesive remover wipes, stoma powder/paste, or deodorizer.
Incomplete Dialysis Assessments and Incorrect Access Site Documentation
Penalty
Summary
The facility failed to ensure that dialysis communication forms were completed with pre-dialysis and post-dialysis assessment information for one resident receiving dialysis services. Resident #5 was admitted with diagnoses including diabetes, end stage kidney disease, dependence on renal dialysis, heart failure, COPD, post-polio syndrome, weakness, depression, and hypertension. The resident had a BIMS score of 15/15 and was observed getting ready to leave for dialysis, stating he went on Tuesday, Thursday, and Saturday. He showed a dialysis access site on his right chest, with a dressing dated 8/20/25. Record review showed physician orders for dialysis on Tuesday, Thursday, and Saturday, monitoring of an AV shunt site every shift for signs and symptoms of infection or bleeding, and monitoring of a new AV fistula site to the left upper arm for bleeding, increased edema, or signs and symptoms of infection. However, the Dialysis Communication Record dated 8/26/2025 identified the dialysis access site as a right chest CVC, while the physician orders identified an AV shunt and AV fistula in the left upper arm. The care plan also addressed infection risk related to a dialysis port but did not identify the location of the dialysis port. Review of 13 Dialysis Communication Records found 3 missing assessment details, including vital signs, weights, and access site information, and on 8/12/2025 the facility assessment section was blank. The dialysis center section for that same date documented that the resident became unresponsive for less than 1 minute due to hypotension and quickly returned to baseline after intermittent fluid boluses. A progress note later stated dialysis staff reported the brief unresponsive episode and fluid boluses, and the resident had not mentioned it. The DON acknowledged that the nurses should have completed the assessment information and that there was a discrepancy between the orders and care plan for the dialysis access site.
Medication Administration Parameters Not Followed
Penalty
Summary
The facility failed to follow physician-ordered medication administration parameters for two residents reviewed for unnecessary medications, resulting in medications being given outside of ordered hold limits. Resident #49 was admitted with diagnoses including diabetes, heart failure, a cardiac pacemaker, repeated falls, COPD, hypertension, dementia, weakness, hypothyroidism, depression, anxiety, peripheral vascular disease, arthritis, and pain, and had a BIMS score of 3/15 with a memory problem and need for assistance with care. His orders included Metoprolol Tartrate 50 mg twice daily with instructions to hold if SBP was less than 110 or heart rate was less than 60, and Hydralazine 10 mg three times daily with instructions to hold if SBP was less than 120. The MAR showed Metoprolol was administered three times when the heart rate was below 60, and Hydralazine was administered when the blood pressure was 118/58. The progress notes did not address the low blood pressures or heart rates or explain why the medications were not held, and the DON stated the nurses should have followed the orders. Resident #31 had diagnoses including type 2 diabetes mellitus, dementia, a history of falling, and delusional disorder. The resident had an order for Lyumjev insulin 2 units subcutaneously before meals, hold if blood sugar was less than 120 and call the physician if more than 300. Pharmacy review had previously identified the need to clarify blood sugar hold levels, and the order was updated, but the MAR showed multiple administrations when blood sugars were below the ordered hold parameter, including readings of 109, 114, 117, 112, 95, 107, 115, 102, 100, and 118. During interview, the DON stated nurses should be holding insulin when parameters were not met unless the physician was notified and approved administration.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement and operationalize processes and procedures to ensure proper pharmacological oversight of controlled and narcotic medications. This deficiency was identified during a survey that included observation, interviews, and record reviews. The survey revealed issues with the accurate electronic order entry, monitoring, and accountability of receipt, dispensing, administration, and disposal of medications in two of three medication carts and one medication room. These failures resulted in expired medications and inaccurate reconciliation of controlled and narcotic medications for five residents, with the potential to affect all 68 residents in the facility. During a tour and narcotic medication reconciliation of the C-Hall medication cart, several discrepancies were noted. For instance, the Control Substance Record for Vimpat for a resident had a line drawn through the last administered dose without an error notation, and the LPN was unable to provide an explanation. Another resident's Ativan count was incorrect, with one pill missing from the blister pack, and the LPN suggested that the prior nurse might not have signed the medication out. Additionally, a blister pack of Xanax was found without a corresponding Control Substance Record, and the Director of Nursing (DON) could not provide an explanation for these discrepancies. Further issues were identified in the B-Hall medication cart and the medication room. A discrepancy in the Xanax count for a resident was noted, with one tablet missing. In the medication room, expired Ativan vials were found without a Control Substance Record. The DON and Assistant Director of Nursing (ADON) were unable to provide satisfactory explanations for these discrepancies, and the facility's policy on controlled substance administration and accountability was not adhered to. The survey also uncovered that a resident received the wrong form of Oxycodone due to an electronic medical record issue, which had not been previously identified.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label, store, and dispose of medications and medical supplies, leading to several deficiencies. During a tour of the C-Hall medication cart, it was observed that multiple medications, including Trelegy Ellipta and DouNeb inhalation solutions, were open and undated, with some being expired. Licensed Practical Nurse (LPN) L confirmed the medications should have been disposed of according to the instructions but was unaware of the specific requirements for some medications. Similar issues were found in the B-Hall and A-Hall medication carts, where expired medications were not discarded, and opened medications were not dated. In the medication room, a refrigerator was found with a significant ice build-up, and expired Ativan vials were present. LPN G was unable to explain why the refrigerator was not maintained or why expired medications were not discarded. Additionally, a green box containing expired backup medications was found, including Epinephrine auto-injectors and Narcan vials. The facility's Director of Nursing (DON) acknowledged awareness of these issues but did not provide further explanation. An unlocked linen closet on A-Hall was found to contain medications and medical supplies accessible to residents, visitors, and staff. The closet, intended for overstock supplies, included various creams, wound care products, and medications. LPN G and Supply Staff M could not explain why the closet was unlocked, despite containing items that should be secured. The facility's policy requires all medications to be stored in locked compartments, which was not adhered to in this instance.
Failure to Ensure Dignified and Respectful Treatment
Penalty
Summary
The facility failed to ensure dignified and respectful treatment for a resident, resulting in staff speaking to the resident in an undignified and belittling manner. The resident, who was admitted with diagnoses including heart failure, respiratory failure, depression, and weakness with bilateral foot drop, expressed feelings of frustration and discontentment. During an interview, the resident reported that some staff acted as if providing care was a burden and specifically mentioned a CNA who spoke to them in a rude tone, rolled their eyes, and failed to return to assist them after being asked to be put to bed. The resident's room was observed to be uncomfortably hot and humid, lacking an air conditioning unit, which contributed to the resident's discomfort. The CNA confirmed providing care to the resident and acknowledged a conversation where they expressed the need to hurry due to the heat in the room. Despite the resident's complaints and reports, no concern or incident forms were received by the conclusion of the survey. The facility's policy on resident rights emphasizes the responsibility to properly care for residents, which was not upheld in this instance.
Failure to Provide Adequate Hygiene and Environmental Care
Penalty
Summary
The facility failed to provide adequate hygiene and daily care for two residents, resulting in unkempt conditions and foul odors. Resident #28 was observed in a room with an uncomfortably hot and humid environment, lacking an air conditioning unit. A pink bedpan was left uncovered on a garbage can next to the bed. The resident's bathroom emitted a strong, pungent odor, which the resident described as unbearable. The resident, who required maximum assistance for daily activities, avoided using the bathroom due to the smell. A CNA confirmed the odor and attributed it to incontinence issues of a neighboring resident. Resident #48 was found sitting in a recliner with a bedside commode nearby, visible from the hallway. The room smelled of feces, and the commode was uncovered with dried stool on the seat and in the bucket. The resident, who was moderately cognitively impaired and required maximum assistance for daily activities, indicated they used the commode only when their brief overflowed. Despite being assigned to care for the resident, a CNA acknowledged the condition of the commode but did not provide an explanation for its state over two days. The facility's policy on Activities of Daily Living, which emphasizes maintaining good grooming and hygiene for residents unable to perform these tasks independently, was not adhered to. The observations and interviews revealed a lack of proper hygiene care and environmental maintenance, contributing to the deficiencies noted in the care of Residents #28 and #48.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to prevent the development of three pressure ulcers in a resident, resulting in one Stage IV ulcer on the coccyx and two unstageable ulcers on the ankles. The resident, who was admitted with multiple diagnoses including Alzheimer's Disease, Diabetes, and Dementia, developed these wounds after being readmitted to the facility following hip fracture surgery. The coccyx wound was not present upon readmission but developed shortly after, as confirmed by the Assistant Director of Nursing (ADON) who conducted the admission skin check. The resident was frequently in a wheelchair and unable to reposition herself, which contributed to the development of the coccyx wound. The ADON acknowledged that the lack of repositioning and prolonged wheelchair use were plausible causes for the wound. Additionally, the resident's bilateral ankle wounds were discovered later and were attributed to the rubbing of soft heel boots against the skin while the resident lay in a fetal position in bed. Despite the use of soft boots, pressure on the ankles persisted, leading to the development of these wounds. The facility's policy on pressure injury prevention and management emphasizes the importance of prompt assessment, treatment, and evidence-based interventions for residents at risk. However, the facility did not adequately implement these measures for the resident, resulting in the development and delayed healing of the pressure ulcers. The wounds were monitored and showed signs of improvement over time, but the initial failure to prevent their occurrence highlights a deficiency in the facility's care practices.
Inadequate Fall Prevention and Documentation
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for fall prevention, resulting in inadequate investigation, documentation, and intervention for two residents. Resident #16 experienced multiple falls, with documentation indicating a lack of accurate Minimum Data Set (MDS) entries and comprehensive analysis of the falls. The interventions implemented post-fall were often repetitive and not meaningful, such as educating the resident to use the call light, which was already an existing intervention. Additionally, there was a lack of documentation regarding the resident's footwear and the accessibility of the call light at the time of the falls. Resident #23, who was severely cognitively impaired and required maximum assistance, also experienced multiple falls. The resident's room was located far from the nurses' station, which was not ideal for a high fall risk individual. Observations revealed that the resident's call light was not within reach, and the wheelchair leg rests were not removed, potentially contributing to the falls. The interventions following the falls were not adequately documented or analyzed to prevent future incidents. The Director of Nursing (DON) was unable to provide explanations for several deficiencies, including the lack of meaningful interventions and the failure to update care plans with new interventions. The facility's policy on fall prevention was not effectively followed, as evidenced by the repeated falls and insufficient post-fall assessments and documentation. The DON acknowledged the need for additional documentation and analysis to implement meaningful interventions.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure proper positioning and adherence to care-planned interventions during enteral feeding for two residents, resulting in potential risks of aspiration and enteral tube malfunction. Resident #19, who was admitted with severe cognitive impairment and required extensive assistance, was observed multiple times in a position that did not comply with the care plan. The care plan specified that the resident should have an abdominal binder on at all times and the head of the bed elevated to 30 degrees during and after tube feeding. However, observations revealed that the resident was often without the abdominal binder and positioned with the head of the bed at an inadequate elevation, sometimes nearly flat. Similarly, Resident #50, who had a history of respiratory failure and cognitive communication deficits, was observed with their head of the bed elevated only between 20 and 25 degrees during enteral feeding, contrary to the care plan requirements. The resident exhibited signs of respiratory distress, such as a moist cough and audible breathing, while being totally dependent on staff for activities of daily living. These observations indicate a failure to follow prescribed care interventions, potentially compromising the residents' safety and well-being.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents using CPAP and oxygen therapy. For Resident #22, the CPAP mask was observed face down and uncovered on the nightstand, and there was no care plan in place for the CPAP machine despite physician orders for its use. Similarly, Resident #67's CPAP mask was also found face down and uncovered, and there was confusion regarding the type of water to be used in the CPAP machine, with the resident indicating that the facility provided purified water, which was unsuitable due to its mineral content. Resident #23 was observed with nasal cannula oxygen tubing not in place, despite the oxygen concentrator being on, and the resident's care plan indicated a need for continuous oxygen therapy at 2L/min. However, the oxygen was set at 1.5L/min, and the LPN was unaware of this discrepancy until it was pointed out. The facility's policy requires oxygen to be administered under physician orders, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate during the survey. Three medication errors were observed among three residents. For one resident, an LPN prepared and attempted to administer an incorrect dose of Valporic Acid, exceeding the prescribed amount by 2 mL. The LPN did not verify the medication amount on a flat surface, leading to the error. Another resident was involved in an error where an LPN reconstituted Aztreonam with an incorrect amount of sterile water, using 1 mL instead of the required 3 mL as per the medication package insert. The LPN was unaware of the reconstitution instructions provided in the medication insert and had previously administered the medication without reconstituting it themselves. A third resident received the wrong form of Oxycodone. The LPN was about to administer Oxycodone IR instead of the prescribed Oxycodone HCL. Upon review, it was found that the resident had been receiving the incorrect medication form for three days. The facility's failure to provide a policy or procedure related to medication administration upon request further highlights the deficiency. These errors indicate a lack of adherence to proper medication administration protocols, potentially compromising resident safety.
Inadequate Hand Hygiene and PPE Use During Resident Care
Penalty
Summary
The facility failed to perform proper hand hygiene and ensure the correct use of Personal Protective Equipment (PPE) during the care of a resident. The resident, admitted with diagnoses including a laceration of the cerebellum, impaired gastrointestinal status requiring enteral feeding, and subdural hemorrhage, required extensive assistance and had severely impaired cognition. On observation, a Certified Nursing Assistant (CNA) used the same gloved hands to perform incontinence care and retrieve items from their pocket, which could lead to contamination. Additionally, a nurse entered the resident's room, donned gloves without performing hand hygiene, and then donned a gown with the same gloved hands. The nurse proceeded to set up wound care supplies and, with the assistance of two CNAs, positioned the resident. The nurse removed the old dressing, cleansed the area, and applied a new dressing on the resident's coccyx wound without changing the gloves or performing hand hygiene.
Failure to Provide Functional Call Light System
Penalty
Summary
The facility failed to provide a functional call light system for two residents, resulting in delayed staff response to their needs. On multiple occasions, a resident was observed using a handheld bell to request assistance, as the call light in their room was broken. Despite ringing the bell for extended periods, no staff responded promptly. The resident expressed frustration and concern about the lack of response, especially in emergency situations. Staff members in the vicinity did not hear the bell, and it was confirmed that the call light had been broken for several days. Another resident in the same room also experienced a broken call light, which was not reported on the maintenance list. The administrator was initially unaware of the duration of the issue and believed the residents had been provided with bells as an alternative. However, the residents and a staff member confirmed the call light had been non-functional for two days. The residents were cognitively intact, indicating they were aware of the situation and its implications. The deficiency was observed during a survey, highlighting the facility's failure to ensure a working call system in the residents' room.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 49 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Cass City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tuscola County Medical Care Facility | 12.5 mi | ★★★★★ | 11 | 0 |
| Huron County Medical Care Facility | 15.4 mi | ★★★★★ | 0 | 0 |
| Courtney Manor | 16.9 mi | ★★★★★ | 10 | 0 |
| Marlette Community Hospital Ltcu | 19.7 mi | ★★★★★ | 0 | 0 |
| Fisher Senior Care And Rehabilitation | 20.4 mi | ★★★★★ | 8 | 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.