Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mymichigan Medical Center Sault during CMS and state inspections, most recent first.
Incomplete Monitoring of a Worsening Stage IV Pressure Injury: A resident with dementia, heart failure, and osteomyelitis had a Stage IV sacral pressure injury that was not effectively monitored for progression. Nursing wound evaluations were incomplete and then absent for an extended period, despite notes of worsening pain, odor, purulent drainage, and deterioration. The wound later showed exposed bone, undermining, eschar, and a large increase in size, and the wound care MD documented osteomyelitis, debridement, IV abx, and NPWT.
Food safety standards were not followed during kitchen operations. Dietary staff prepared food without beard restraints, food was observed next to an open garbage can, and multiple items in refrigerators and freezers were unmarked, undated, or past use-by dates. Staff also handled a floor-contaminated eraser and then continued food prep without removing gloves or washing hands, and the RD acknowledged the storage and hand hygiene failures.
Failure to Offer Current COVID-19 Vaccination to Residents: The facility did not document screening, offering, or resident acceptance/declination of the current COVID-19 vaccine for multiple residents. Some residents had prior COVID-19 vaccination or declination records, but there was no evidence the 2025-26 vaccine was offered or documented in the EMR. The DON reported there was no formal process in place for ensuring residents were screened or offered the current vaccine, and no vaccines had been administered at the time of the interview.
A resident with anxiety, depression, diabetes, and moderate cognitive impairment had antibiotic ointment and eye drops at the bedside, but the EMR did not show a physician order or completed assessment allowing self-administration. The DON confirmed the assessment had not been done and stated the resident would not be safe to self-administer medications.
The facility failed to provide written transfer notifications and bed hold policy information to two residents or their representatives when they were sent to the ER/hospital. One resident was transferred after acute symptoms including low O2, fever, shaking, and emesis, and another was sent after a physician ordered ER transfer with the resident’s agreement. Record review found no evidence that the required written notices or bed hold information were provided for either transfer.
Failure to Address Abuse-Related Psychosocial Needs: A resident with anxiety, depression, and moderate cognitive impairment reported that her son punched her near her pacemaker, stole money from her, and threatened to kill her. She was tearful and scared, but social services notes did not address her statements or document outside referrals, and staff acknowledged the concern was not added to the care plan or followed up with psych support.
Delayed Review of Pharmacy MRR Recommendations: Two residents with cognitive impairment and multiple diagnoses had consultant pharmacist MRR recommendations that were not reviewed and acted on in a timely manner. One resident’s psychotropic GDR recommendation was not signed off by the physician for about three months, and the other resident had delayed physician review of risperidone recommendations plus unresolved follow-up on insulin-related recommendations that were deferred to another physician without documentation that they were forwarded or tracked.
Failure to Monitor and Justify Ongoing Antibiotic Use: A resident with dementia and UTI remained on daily Bactrim for chronic UTI prevention even after a urine C&S showed E. coli resistant to Bactrim. The pharmacist questioned whether the medication was helping and recommended re-evaluation, but the physician declined without documenting a clear rationale, and the DON/IP stated she could not provide a reason for the continued prophylactic antibiotic.
A facility failed to protect two residents from sexual abuse when a resident exposed himself and solicited another resident in the dining room. The resident had a known history of inappropriate sexual behavior, yet staff did not adequately supervise or redirect him. The care plans for both residents were insufficient in addressing the risks, leading to a deficiency in protecting residents from abuse.
The facility failed to adhere to care plans for safe transfers, resulting in harm to two residents. One resident, requiring two-person assistance, was transferred by a CNA alone, leading to a fall and femur fracture. Another resident, care planned for a sit-to-stand lift, was transferred with a gait belt due to equipment issues, contrary to the care plan. Staff were not alerted to changes in care plans, and the facility lacked a policy on safe transfers.
A facility failed to report a resident-to-resident sexual abuse incident to the state agency. Two residents with cognitive impairments were involved in an incident where one resident was observed holding the other's exposed penis in the dining room. Although the incident was reported internally, it was not reported to the state agency, nor was it investigated, contrary to the facility's policy.
The facility failed to update care plans for two residents after an altercation, where one resident with severe cognitive impairment was found holding another resident's exposed penis. Despite the incident, care plans were not revised to include interventions, contrary to facility policy.
The facility failed to conduct a thorough investigation into a potential abuse incident involving two residents. A resident was asked to touch another on the groin, and the incident was reported by a staff member. However, the investigation lacked witness statements and an incident report, contrary to the facility's policy. This resulted in the potential for undetected abuse.
The facility failed to maintain food safety and sanitation standards, with issues including improper storage and labeling of food, lack of sanitization in dishwashing processes, and incomplete temperature monitoring in freezers. These deficiencies could lead to foodborne illnesses among residents.
The facility's QAPI committee meetings lacked consistent attendance by required members, including the Medical Director, which could lead to ineffective coordination of care and delayed issue resolution, affecting all 35 residents.
The facility failed to provide necessary adaptive dining equipment for several residents, leading to difficulties in food consumption. A resident used regular utensils despite needing food cut into bite-size pieces, another ate with fingers instead of using a divided plate, and a third had uncovered beverages despite needing a cup with a lid. Additionally, a resident was given a plastic fork due to a shortage of proper utensils, impacting her ability to eat effectively.
The facility failed to notify two residents, their representatives, and the Long-Term Care Ombudsman of hospital transfers. One resident was transferred in September, and another in July, with no documentation of notification in their EMRs or on the Ombudsman transfer logs. The facility's policy lacked instructions on providing such notifications.
The facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to hospital transfers for two residents. One resident was transferred to the hospital and returned without documentation of being informed about the bed-hold policy. Another resident was transferred to the emergency department and admitted to the hospital, also without documentation of notification. The facility's transfer and discharge policy lacked instructions on providing a bed-hold agreement.
A facility failed to assess and treat a resident's acute change in condition, resulting in abdominal discomfort and nausea. The resident, who required assistance with transfers and toileting, was observed to be nauseous and vomiting, with no documented physical assessment or physician notification. The facility did not implement bowel care standing orders until five days after the last recorded bowel movement, and there was no documentation of refusals or physician notification during this period.
A resident with severe cognitive impairment and arthritis was not provided with necessary feeding assistance, leading to potential weight loss. Despite care plan recommendations for increased monitoring and assistance, staff left the resident unattended with meals out of reach, resulting in untouched food and drinks. The facility's feeding policy lacked specific instructions for the resident's needs.
A facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. An LPN did not follow the manufacturer's instructions for priming and administering insulin to a resident, leading to medication errors. The LPN primed insulin pens incorrectly and did not hold the needle in place for the recommended duration after injection, contributing to the facility's high error rate.
The facility failed to serve prescribed therapeutic diets to three residents, leading to potential health complications. A resident with diabetes and obesity was served two cookies instead of one, contrary to their low sugar diet order. Another resident with dementia and uncontrolled diabetes received a full dessert portion, despite needing a half portion. A third resident with a history of stroke and diabetes was also given a full dessert portion. Dietary staff confirmed that all desserts were served in the same size, regardless of dietary restrictions.
A facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with Alzheimer's, diabetes, and a stage two pressure injury, despite a physician's order and CDC guidelines. The LPN and CNA did not wear protective gowns, and the LPN was unaware of the EBP requirement, posing a risk of spreading MDROs.
Incomplete Monitoring of a Worsening Stage IV Pressure Injury
Penalty
Summary
The facility failed to effectively monitor a resident’s Stage IV sacral pressure injury for progression. The resident had diagnoses including heart failure, dementia, osteomyelitis, and a Stage 4 pressure ulcer of the sacral region, and required substantial to maximal assistance for toileting and bed mobility, was dependent for transfers, and had mild cognitive impairment. On observation, the wound was large, irregularly shaped, and extended across the sacral region into the coccyx and gluteal cleft, with exposed bone, eschar, undermining, and dark purple and black tissue. An IV line was present in the resident’s right upper arm, and a wound vac was in use. Record review showed incomplete wound evaluations on 11/05/2025, 11/11/2025, and 11/25/2025, with missing documentation of wound bed description, signs and symptoms of infection, exudate, peri-wound condition, wound pain, and treatment provided. The 11/17/2025 evaluation documented granulation tissue, slough, eschar, heavy sanguineous drainage, moderate odor after cleansing, rolled edges, denuded and macerated surrounding tissue, and induration extending more than 50% around the wound, with the progress marked deteriorating. The 11/25/2025 evaluation again lacked the remaining assessment details. No further nursing skin and wound evaluations were found in the EMR from 11/25/2025 through 1/12/2026. Progress notes during this period documented worsening wound-related findings, including increased pain during wound care, saturated dressings with purulent and serosanguinous drainage, foul odor, and continued deterioration. The wound care physician documented that the ulcer was larger, worse, and required debridement; later notes described odor, exposed bone, and MRI-confirmed sacral osteomyelitis. The physician ordered IV ceftriaxone and negative pressure wound therapy, and the wound vac was placed on 12/24/2025. On 1/14/2026, the DON confirmed that wound care evaluations were not documented from 11/25/2025 through 1/12/2026 and that the earlier evaluations were incomplete, stating there was a need for a cohesive documentation system to ensure changes in wound status were quickly identified.
Food storage, labeling, and hand hygiene failures in kitchen
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional food safety standards. During kitchen observations, Dietary Staff C and Dietary Staff D were preparing food without beard restraints, and Dietary Staff C stated he does not normally wear a beard restraint while working in the kitchen. The Registered Dietitian acknowledged that staff with long facial hair are to wear beard restraints, and the facility policy titled Food Safety Management System stated that food employees must wear hair restraints such as hats, hair coverings or nets and beard restraints. Additional observations identified multiple food storage and sanitation issues. An open rack with muffins and cookies was placed directly adjacent to an open garbage can. The #9 refrigerator contained sliced tomatoes that were unmarked and undated, and the #12 freezer contained mini cupcakes removed from the original box with no date taken out or use-by date. The #1 refrigerator contained opened Monterey jack cheese past its use-by date, opened Asiago cheese with no open or use-by date, and yellow squash dated 12/19/25 that appeared shriveled with brown spots. The large sugar bin and a flour bin each contained open bags with no open date or use-by date. During food preparation, Dietary Staff D picked up an eraser from the floor while wearing gloves, did not remove the gloves or wash his hands, and then handled a pan and non-stick spray. The Registered Dietitian acknowledged the items in the refrigerators were incorrectly stored and that the hand hygiene was not performed after the contamination event.
Failure to Offer Current COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that the current 2025-26 COVID-19 vaccine was offered to five residents reviewed for COVID-19 vaccination status, including residents who had been admitted to the facility and had no documentation in the EMR showing that they were screened, offered, received, or declined the current vaccine. Resident #1 had a signed declination for the 2024-25 COVID-19 vaccine, but there was no documentation for the 2025-26 vaccine. Resident #3 had no documentation regarding COVID-19 immunization status. Resident #7 had no documentation of screening for COVID-19 immunization upon admission or afterward. Resident #21 and Resident #25 both had prior COVID-19 vaccinations documented, but no documentation that they were offered or declined the current 2025-26 vaccine. The DON, who reported serving as the facility's Infection Preventionist, stated she was new to the role and had recently discovered there was no formal process in place to ensure residents were screened for COVID-19 immunization or offered the current vaccine. She stated the 2025-26 vaccine should have been offered as soon as it became available and reported that she had begun screening residents and contacting resident representatives the prior week, but no vaccines had been administered at the time of the interview. The facility policy titled Admission Process/Pre-Screening stated that immunizations would be reviewed prior to admission care conference, that vaccinations not up to date would be offered using CDC guidance, that consents or declinations would be documented in the resident chart, and that COVID-19 immunizations would be offered annually.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to perform an assessment for self-administration of medication for one resident who had medications at the bedside. The resident had diagnoses including anxiety disorder, depression, and diabetes mellitus, and the MDS reflected a BIMS score of 12 out of 15, indicating moderate cognitive impairment. During observation, the resident had a tube of antibiotic ointment and a small bottle of eye drops on the bedside table, and the resident stated the eye drops were used for dry eyes and the ointment was for a scratch on the forearm. Review of the EMR did not show a physician order allowing the resident to self-administer any medication, and no self-administration assessment had been completed. The DON confirmed the assessment had not been done and stated the resident would not be safe to self-administer medication. The DON also reported being unaware that the resident had medications at the bedside and expressed concern that people can become sick if they ingest medications not meant for them.
Failure to Provide Written Transfer and Bed Hold Notifications
Penalty
Summary
The facility failed to ensure that residents or their representatives were provided written notification of transfer and/or the facility’s bed hold policy at the time of transfer out of the facility or anytime thereafter for two residents reviewed for hospitalization. For Resident #1, the record showed a hospitalization on 11/17/2025 after a CNA found the resident gargling, with a wet cough, low oxygen saturation, fever, shaking, and emesis after coughing; the resident was then taken to the emergency room via stretcher. The record contained no evidence that the resident or representative received written notification of the reason for transfer or information about the facility’s bed hold policy related to that transfer. For Resident #3, the record showed the physician ordered transfer to the ER after speaking with the resident, who agreed to go, and the resident was transferred to the hospital on 11/28/2025. The record contained no evidence that the resident or representative received written notification of the reason for transfer or information regarding the facility’s bed hold policy for that hospitalization. During interviews, the DON and an RN described the process for completing and providing transfer/discharge notifications and bed hold information, but the record review confirmed no written notification or evidence of receipt of the bed hold policy for either resident’s transfer.
Failure to Address Resident Abuse-Related Psychosocial Needs
Penalty
Summary
The facility failed to provide medically-related social services to a resident with anxiety disorder, depression, and moderate cognitive impairment who reported verbal and physical abuse by her son. The resident stated that her son punched her near her pacemaker, stole $9,000 from her, and threatened to shoot her in the head if he ever saw her again. During observation, she was tearful, wiped her eyes, blew her nose, curled up on the edge of her bed, and said she was scared and wanted to talk with someone. The social services record did not address the resident’s statements that her son wanted to kill her, and no outside referral services were documented. During interview, Social Services staff acknowledged that the son had punched the resident near her heart and threatened to kill her, that the DPOA/legal guardian did not want him to see her, and that staff had not been informed or the care plan updated. The staff member also stated that the resident had been upset and that a referral to psych services for emotional and behavioral assistance should have been sent, but follow-up had not occurred. The admission and care planning records reflected that the resident had depression and anxiety, and the initial social services assessment noted mood and behavior concerns with a consult to a psych NP checked. However, review of social services notes did not show attention to the resident’s fear of her son or any referral for outside services. The facility’s care planning policy required a comprehensive care plan based on interdisciplinary assessments, including identified concerns, goals, and interventions, but the resident’s psychosocial concerns related to abuse and fear were not comprehensively addressed in the plan of care.
Delayed Review of Pharmacy MRR Recommendations
Penalty
Summary
The facility failed to ensure timely review and follow-up of consultant pharmacist medication regimen review recommendations for two residents. One resident had Alzheimer’s disease, depression, adjustment disorder, and severe cognitive impairment with a BIMS score of 5 out of 15. The other resident had renal insufficiency, diabetes, Alzheimer’s disease, anxiety, depression, bipolar disorder, and moderate cognitive impairment with a BIMS score of 9 out of 15. For the first resident, the consultant pharmacist recommended a gradual dose reduction of Abilify because the resident had only one behavior noted in the prior month and was also receiving other psychotropic medications, including Remeron, Zoloft, and Ingrezza. The pharmacist’s recommendation was dated 6/06/2025, and a handwritten behavior committee note was added by LBSW A on 6/18/2025 stating that GDR was not recommended at that time. The physician did not sign and address the recommendation until 9/18/2025, about three months later, and declined it based on continued behaviors noted by CNA staff. For the second resident, the consultant pharmacist made multiple recommendations related to psychotropic and diabetes medications. The pharmacist recommended a GDR of risperidone because no behaviors were noted, but the behavior committee note stated previous GDRs resulted in suicidal ideation and actions, and the physician did not address the recommendation until 9/19/2025, about three months later. The pharmacist also recommended changes to scheduled Humalog dosing on 9/04/2025 and again on 11/06/2025 because prolonged sliding scale insulin use was not recommended; the reviewing physician declined both recommendations with a note to defer to Physician G. The consultation reports contained no indication that the recommendations were forwarded to Physician G or that follow-up occurred, and the DON stated she was unsure whether Physician G had received them. The NHA reported he did not believe the facility had a specific policy for completion of the consultant pharmacist’s MRRs, and the pharmacy agreement contained no language describing the facility’s process or responsibility for review and follow-up.
Failure to Monitor and Justify Ongoing Antibiotic Use
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program for Resident #29, who had diagnoses including dementia and a urinary tract infection. Review of the resident’s EMR showed an active order for Bactrim 400-80 mg, one tablet by mouth each morning for chronic UTI, with a start date of 2/8/2025. A pharmacist consultation report dated 7/03/2025 stated the resident had received Bactrim daily for UTI prevention since 2/8/2025 and noted that the resident recently had a UTI with a sensitivity report showing resistance to Bactrim, after which Macrobid was started for 5 days. The pharmacist recommended re-evaluating continued daily Bactrim use and considering discontinuation or documenting the benefit if continued. The attending physician declined the recommendation and wrote to continue current dosing of Bactrim, but no further reason for continuing the medication was included in the rationale. A duplicate consultation report in the EMR also showed the physician declined the recommendation and wrote to continue daily Bactrim without additional rationale. Review of the urine culture and sensitivity from 6/30/2025 showed 100,000 COL/ML E. coli, with Bactrim listed as resistant and the only resistant antibiotic among 14 listed. During interview, the DON, who was also the Infection Preventionist, stated she could not provide a rationale for the continued prophylactic Bactrim because the physician had not provided one.
Failure to Prevent Sexual Abuse in LTC Facility
Penalty
Summary
The facility failed to protect two residents from sexual abuse, resulting in a deficiency. On February 23, 2025, a Certified Nursing Assistant (CNA) witnessed a resident, R10, exposing himself and asking another resident, R11, to touch his exposed penis in the dining room. R10 had a history of inappropriate sexual behavior, including public masturbation and coercion, which was known to the facility staff. Despite this knowledge, the staff did not adequately supervise or redirect R10 to prevent the incident. R10 was cognitively intact with a history of anxiety, sleep disorder, and dementia, while R11 had severe cognitive impairment and required assistance with mobility. R10's inappropriate behavior had been documented in the past, including an incident on January 19, 2025, where he was found in a compromising situation with R11. The facility's care plan for R10 acknowledged his risk for inappropriate sexual behavior but failed to implement effective interventions to prevent such incidents from occurring. The facility's policy on abuse prevention emphasized the need for supervision and immediate response to protect residents. However, the staff's actions were insufficient in preventing R10's behavior from escalating. The care plan for R11 did not address the risk of exposure to R10's behavior, leaving her vulnerable to further incidents. The facility's failure to anticipate and prevent the incident on February 23, 2025, despite prior knowledge of R10's behavior, resulted in a deficiency in protecting residents from abuse.
Failure to Follow Care Plans for Safe Transfers
Penalty
Summary
The facility failed to follow care planned interventions for safe transfers, resulting in harm to two residents. Resident #1, who had severe cognitive impairment and required substantial assistance for transfers, was transferred by a CNA as a one-person assist, contrary to the care plan that required two-person assistance. This led to a fall, causing a right femur fracture and necessitating surgical intervention. The CNA did not check the care plan prior to the transfer and assumed the transfer status had not changed based on past observations. Resident #3, also with severe cognitive impairment and a history of falls, was care planned for a two-person assist using a sit-to-stand lift with a yellow sling. However, during an observed transfer, a green sling was used due to the unavailability of the yellow sling, and the resident was transferred with a gait belt and two-person assist instead. This was not in accordance with the care plan, and the staff involved were unsure of the facility policy regarding such transfers. The resident's transfer status had been recently changed, but staff were not alerted to these changes, leading to inappropriate transfer methods being used. The Director of Nursing confirmed that the root cause of the incidents was the staff's failure to follow the comprehensive care plans for the residents' transfer statuses. The facility lacked a specific policy on safe, staff-assisted transfers, and staff were expected to check care plans daily for any changes. The incidents highlight a lack of communication and adherence to care plans, resulting in unsafe transfer practices and harm to residents.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to notify the state agency of a resident-to-resident sexual abuse allegation involving two residents. Resident #1, who had moderate cognitive impairment due to dementia and depression, was involved in an incident with Resident #3, who had severe cognitive impairment due to dementia, anxiety disorder, and depression. The incident occurred in the dining room where Resident #3 was observed holding onto Resident #1's exposed penis. This incident was reported by a Certified Nurse Aide to a Registered Nurse, who then informed the Director of Nursing. Despite the report being made internally, the Nursing Home Administrator acknowledged that the incident was not reported to the State Agency. Furthermore, the Director of Nursing confirmed that the incident was neither investigated nor reported to the state. The facility's policy requires that all allegations of abuse, neglect, or mistreatment be reported to state officials within 24 hours and investigated with results reported within five working days, which was not adhered to in this case.
Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to ensure that care plans were updated and revised appropriately for two residents, resulting in care plans that did not reflect the residents' needs. Resident #1, who was admitted with diagnoses of dementia and depression, exhibited moderate cognitive impairment. Resident #3, admitted with dementia, anxiety disorder, and depression, showed severe cognitive impairment. An incident occurred where Resident #3 was found holding onto Resident #1's exposed penis in the dining room, indicating a resident-to-resident altercation. Despite this incident, the care plans for both residents were not updated or revised to include interventions to mitigate such altercations. The Director of Nursing confirmed that the care plans were not reviewed or revised following the incident, although the facility's policy states that care plans should be revised after each incident. The facility's policy also requires that care plans be implemented with documentation in the resident's clinical record and evaluated periodically to reflect the resident's condition.
Incomplete Investigation of Potential Abuse Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an incident of potential abuse involving two residents. The incident was reported when a Registered Nurse (RN) observed one resident asking another to touch him on the groin, which was followed by the resident complying with the request. The residents were immediately separated, but the investigation into the incident was incomplete. The facility's investigation folder lacked witness statements from the staff members who were present during the incident, including the Resident Assistant who initially reported the event and the RN who separated the residents. Additionally, other residents and staff present in the dining room during the incident were not interviewed, and no incident report was completed in the electronic medical record. The facility's policy on abuse, neglect, or mistreatment requires that all allegations be thoroughly investigated, including obtaining witness statements and completing an incident report. However, the investigation into this incident did not adhere to these requirements. The Nursing Home Administrator was unable to provide explanations for the lack of witness statements and the absence of an incident report. This failure to follow the facility's policy resulted in the potential for undetected abuse, as the investigation did not gather sufficient information to determine the nature and extent of the incident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in potential contamination of food items. During a kitchen tour, it was observed that two walk-in freezers lacked internal thermometers and had significant ice accumulation, which could lead to thawing and refreezing of food. The temperature logs for these freezers were incomplete, with several days missing temperature recordings. Uncovered food items, such as cooked rice, marinara sauce, and chili, were stored improperly, increasing the risk of contamination. Additionally, the facility did not properly clean and sanitize dishes and utensils. The three-compartment sink used for washing, rinsing, and sanitizing food contact surfaces was found to have no sanitizer present, as indicated by test strips showing 0 ppm. The sanitizing bucket for food preparation surfaces also registered 0 ppm, indicating a lack of effective sanitization. This failure to maintain proper sanitization levels could lead to the spread of foodborne illnesses among residents. The facility also failed to ensure that food items were properly labeled and dated. During a tour of the LTC satellite kitchen, several food items, including meat patties, hot dogs, omelets, and potato patties, were found unlabeled and open to air, with unreadable or missing use-by dates. This lack of proper labeling and dating could result in the use of expired or spoiled food, posing a health risk to the residents. The Director of Nursing acknowledged the issue and indicated that dietary staff would be alerted.
Inconsistent QAPI Committee Attendance
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program committee was consistently composed of the required members, as per their policy. The Nursing Home Administrator (NHA) indicated that the QAPI committee had shifted from meeting quarterly to monthly. However, upon reviewing the meeting attendance records, it was found that the committee did not consistently include all required members. Specifically, the Medical Director was absent from several meetings, including those held on 6/20/24, 9/19/24, and 10/17/24. Additionally, the NHA was not present at the meeting on 7/18/24. The facility's policy, last revised in September 2023, mandates the presence of the LTC Medical Director, Director of Nursing, a member of management, and at least three other employees at each meeting, but does not require the Infection Preventionist's attendance. This inconsistency in committee composition resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, thereby placing all 35 residents at risk for quality care concerns. The absence of key members, particularly the Medical Director, from multiple meetings could hinder the committee's ability to effectively address and resolve quality assurance and performance improvement issues within the facility.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide appropriate dining adaptive equipment for four residents, leading to increased difficulty with food consumption and independent eating. Resident #26 was observed using regular utensils despite a care plan indicating no knives and food cut into bite-size pieces. A CNA removed the knife without explanation and was unsure of the reason. Resident #23 was seen eating with her fingers on a regular plate, although her meal tray card specified the use of a divided plate, which a CNA acknowledged would assist her. Resident #3 had uncovered beverages despite instructions for a cup with a lid, which was noted on her meal tray card. Resident #24 was given a plastic fork instead of the appropriate utensils, which hindered her ability to eat effectively. She expressed difficulty eating with the plastic fork and a need for a spoon for her dessert. The meal tray card did not indicate a need for plastic utensils, and staff admitted to running out of forks, resulting in the use of plastic forks for several residents. These observations highlight the facility's failure to adhere to care plans and provide necessary adaptive equipment, potentially impacting residents' nutritional intake.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to the resident, their representative, and the Long-Term Care Ombudsman for two residents. Resident #16 was transferred to the hospital on 9/13/24 and returned on 9/16/24, but there was no documentation of notification in the electronic medical record (EMR) for the resident or their representative. Additionally, the September Ombudsman transfer log did not list this transfer, and the Nursing Home Administrator (NHA) acknowledged that notices of transfer had not been completed following a change in leadership. Similarly, Resident #1 was transferred to the emergency department on 7/29/2024 and admitted to the hospital, but there was no documentation of notification of transfer or discharge in the EMR for the resident or their representative. The July 2024 transfer and discharge list provided to the Long-Term Care Ombudsman also did not include this transfer. The facility's policy on transfers and discharges, last revised in 9/2023, lacked instructions on providing notification to the resident, their representative, or the Ombudsman, contributing to the deficiency.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to hospital transfers for two residents. Resident #16 was transferred to the hospital on 9/13/24 and returned on 9/16/24, with no documentation indicating that the resident or their representative was informed about the bed-hold policy at the time of transfer or after hospitalization. During an interview, the Nursing Home Administrator confirmed that the bed-hold policy was not reviewed with the resident or the responsible party at the time of transfer. Similarly, Resident #1 was transferred to the emergency department on 7/29/2024 and admitted to the hospital, with no documentation showing that the resident or their representative was provided information on the bed-hold policy at the time of transfer or after hospitalization. A review of the facility's policy on transfers and discharges, last revised in 9/2023, revealed that it did not include any instructions related to providing a bed-hold agreement before or upon transfer out of the facility.
Failure to Assess and Treat Constipation
Penalty
Summary
The facility failed to physically assess an acute change in condition and timely identify and treat constipation for a resident, resulting in abdominal discomfort and nausea. The resident, who was cognitively intact and required extensive assistance with transfers and toileting, was observed to be nauseous and vomiting, with no documented physical assessment or physician notification. The Licensed Practical Nurse was aware of the resident's condition but unsure of the cause, and the Director of Nursing confirmed that a physical assessment and blood glucose check should have been conducted. The resident's electronic medical record revealed no bowel movements for six days, and the bowel care standing orders were not implemented until five days after the last recorded bowel movement. There was no documentation of refusals of bowel care or physician notification during this period. The resident experienced another three-day period without a bowel movement, with no initiation of bowel protocol or documented refusals. The facility's failure to assess and address the resident's condition promptly led to the deficiency.
Failure to Provide Feeding Assistance to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide appropriate feeding assistance to a resident with severe cognitive impairment and arthritis, leading to the potential for decreased intake and weight loss. The resident, who had a history of weight loss and underweight BMI, required increased cueing and assistance during meals due to cognitive decline and dexterity issues. Despite recommendations for the resident to dine in the main dining room for better monitoring and assistance, observations revealed that the resident was left unattended in her room with her meal tray out of reach, resulting in untouched meals. On multiple occasions, staff members were observed delivering meals to the resident's room without providing the necessary cueing or assistance. The resident was found sleeping or confused, with meals left untouched and drinks unopened. Staff members failed to enter the room to assist the resident, despite the care plan indicating the need for supervision and assistance during meals. The facility's policy on feeding did not include specific instructions for providing assistance as per the resident's care plan, contributing to the deficiency.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate during the survey. This deficiency was observed in the administration of insulin to a resident. The Licensed Practical Nurse (LPN) involved did not follow the manufacturer's instructions for priming and administering insulin using the Humalog KwikPen and Lantus Solostar pens. Specifically, the LPN primed both insulin pens with the needle pointed sideways instead of upwards, as recommended by the manufacturer. Additionally, the LPN did not hold the needle in place for the recommended duration after administering the insulin doses. The incident involved a resident who was prescribed both rapid-acting and long-acting insulin. The LPN prepared and administered 13 units of Humalog insulin and 25 units of Lantus insulin to the resident. However, the LPN acknowledged not adhering to the manufacturer's guidelines, which included holding the needle in place for at least five seconds for Humalog and ten seconds for Lantus after injection. These actions led to the medication error, contributing to the facility's failure to meet the required medication error rate standard.
Failure to Serve Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were served as prescribed for three residents, leading to potential health complications and an inability for residents to meet their dietary goals. Resident #14 was observed eating two oatmeal raisin cookies, despite the meal tray card indicating a 1/2 portion dessert was required. The Certified Dietary Manager (CDM) confirmed that the resident should have received only one cookie, as per the low sugar diet order. The resident's care plan emphasized the need for a low sugar diet due to obesity and diabetes, with a focus on weight management and portion control. Similarly, Resident #26 was served two cookies instead of the prescribed one, as indicated by the meal tray card for a low sugar diet. The CDM explained that the caution statement on the tray card meant that only half portions of desserts should be served. The resident's care plan highlighted issues related to dementia, poor intake, and uncontrolled diabetes, necessitating careful dietary management to prevent further health complications. Resident #34 was also served a full portion of cherry pie, contrary to the instruction for a 1/2 portion dessert on the tray card. The resident's care plan noted a history of stroke, diabetes, and poor intake, requiring adherence to a low sugar diet. During interviews, dietary staff acknowledged that all desserts were served in the same portion size, regardless of dietary restrictions, indicating a systemic issue in the facility's dietary service practices.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident, leading to a potential risk of spreading multidrug-resistant organisms (MDROs). The resident, who was admitted with Alzheimer's dementia, diabetes, bullous pemphigoid, and a stage two pressure injury, had a physician's order for EBP due to the presence of wounds. Despite a sign indicating the need for EBP being posted at the resident's doorway, the Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) did not wear protective gowns during the wound care procedure. The LPN, when interviewed, stated she was unaware of the requirement for EBP during the resident's wound care. The resident's electronic medical record and care plan both indicated the necessity for EBP with high-contact activities, as per the physician's order and CDC guidelines. These guidelines emphasize the use of gowns and gloves for residents with wounds to prevent the spread of MDROs, highlighting the facility's failure to adhere to established infection control protocols.
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 46 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 Sault Ste. Marie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Sault Ste. Marie | 0.9 mi | ★★★★★ | 46 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mymichigan Medical Center Sault.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.