Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Newaygo Co Medical Care Facility during CMS and state inspections, most recent first.
Failure to Provide Written Transfer and Bed Hold Notifications: The facility did not document that two residents or their responsible parties were given written notice of the reason for hospital transfers and/or the bed hold policy. One resident had COPD, chronic respiratory failure with hypoxia, CHF, and moderate cognitive impairment, with multiple hospitalizations and no record of written transfer or bed hold notices. Another resident was cognitively intact, was transferred to the ER after reporting blood in her brief and constipation, and the EMR showed only a phone call to the spouse; there was no written transfer notice and the bed hold form sent was blank.
Failure to update and implement fall care plan interventions for two residents. One resident with Parkinson's disease, dementia, and hallucinations had prior interventions for a DPM mattress and a walker reminder sign that were no longer in place, and an LPN/UM could not say when they were removed. Another resident with cerebrovascular disease and dementia had a new intervention for a urinary leg bag after tripping over catheter tubing, but a CNA was unaware of the change and had not reviewed the care plan before assisting him.
Failure to follow bowel protocol for a resident with severe cognitive impairment and chronic constipation. The resident had repeated episodes of hard stool, visible stool in the rectal vault/anus, abdominal distention, and multiple stretches of several days without a BM. The care plan required bowel protocol interventions, and the facility’s protocol and orders called for MOM, then a suppository, then an enema after 3 days without a BM, but the record showed delayed and inconsistent use of the ordered bowel regimen, which the DON validated as noncompliance.
Narcotic reconciliation was not consistently followed for 1 of 6 med carts. A Fentanyl Patch Proof of Use Form for a resident showed entries with only one nurse signature, then later the same entry had two signatures even though an RN stated she signed it without witnessing the patch destruction. An LPN stated that signing a proof of use form without witnessing destruction was not standard practice, and the facility policy required another nurse to verify destruction of the used fentanyl patch.
Surveyors found that smoke barrier walls above the ceiling at cross corridor doors in two wings had wire bundle penetrations within the electrical conduit, compromising the required 1/2-hour fire resistance rating. This deficiency was confirmed by maintenance staff and could affect occupants in adjacent smoke compartments.
A deficiency was found when a wheel chair battery charger was used overnight in a resident's room, without the required fire barrier or automatic fire extinguishing system. Maintenance staff confirmed the charging practice, which did not meet fire safety requirements for hazardous areas and could affect two occupants if a hazardous gas release occurred.
The facility failed to follow policies and procedures, monitor, and assist a resident in preventing accidents and hazards related to toileting. The resident, who required partial/moderate assistance, was observed self-transferring without supervision, leading to multiple falls. Care plan interventions were not effectively implemented or monitored, and staff were unaware of the resident's current ambulatory status. The facility's policies on fall prevention and post-fall evaluations were not adequately followed.
The facility failed to ensure that an insulin pen was labeled with the resident's name for one of the two medication carts inspected. During an inspection, a previously used Humalog insulin pen without a resident's name on it was found in an unlabeled compartment. Staff admitted that without the label, they would not know for sure which resident the insulin pen belonged to, creating a potential risk for residents to receive medication from another resident's pen.
Failure to Provide Written Transfer and Bed Hold Notifications
Penalty
Summary
The facility failed to notify residents or their responsible parties in writing of the reason for hospital transfers and/or the facility’s bed hold policy for 2 of 3 residents reviewed for hospitalizations. Resident #43 had diagnoses including COPD, chronic respiratory failure with hypoxia, and CHF, and had a BIMS score of 11 indicating moderate cognitive impairment. Review of the EMR and census information showed multiple hospitalizations, but there was no documentation that R43 or the medical DPOA were notified in writing of the reason for any transfer or of the bed hold policy. The DON confirmed the facility did not send a transfer notification to the medical DPOA for any hospitalization and stated the bed hold notice was sent with the resident during transfer and not retained in the EMR. Resident #58 was cognitively intact with a BIMS score of 14 and was her own responsible party, with her spouse listed as the first emergency contact. After reporting blood in her brief and inability to have a bowel movement, the physician/provider ordered transfer to the emergency room and the spouse was called before the resident was sent by ambulance. However, the EMR did not show any documentation that R58 or her spouse was notified in writing of the reason for the hospital transfer, and it also did not show that the bed hold policy was provided in writing or verbally at the time of transfer or soon thereafter. During interviews, the DON stated she believed a verbal explanation to the family was sufficient and later confirmed the bed hold policy was not given in writing and that the copy sent with R58 was blank.
Failure to Update Fall Care Plans and Communicate Interventions
Penalty
Summary
The facility failed to update and implement fall care plan interventions for two residents reviewed for accidents and falls. One resident had diagnoses including Parkinson's disease, dementia, delusional disorders, and hallucinations. His fall care plan had included a DPM mattress to define the edges of the bed and a sign on his walker to remind him to use it when ambulating, but during observation and interview these interventions were no longer in the room and had been discontinued. The LPN/UM reported she could not recall when the interventions were removed, stated the resident no longer used his walker even though it remained in the room, and was unsure how the updated fall care plan was missed. Staff also reported that the updated plan of care was placed in the resident's closet for review. The second resident had diagnoses including cerebrovascular disease, dementia, and hypertension. His current fall care plan directed staff to use a urinary leg bag when he was up in his wheelchair as tolerated after he attempted to ambulate from his wheelchair and tripped over urinary catheter tubing. During observation, the resident was seated in his wheelchair with a catheter bag underneath it in a privacy bag, and a CNA stated he was not aware of the recent fall intervention and had not reviewed the plan of care before assisting the resident from bed to the dining room. The DON stated the fall care plan should have been updated with new or discontinued interventions after a fall and that staff are expected to review plans of care before assisting residents. Facility policy stated that when any resident experiences a fall, the facility will review the resident's care plan and update as indicated.
Failure to Follow Bowel Protocol
Penalty
Summary
The facility failed to initiate and properly follow the bowel protocol for a resident with vascular dementia, CHF, and anxiety disorder who had severe cognitive impairment with a BIMS score of 6. The resident’s care plan identified a risk for altered bowel and bladder elimination related to limited mobility and included a goal of having a normal bowel movement at least every third day, with interventions to follow the facility bowel protocol and provide bowel medication as ordered. The resident’s record documented repeated episodes of constipation and hard stool with visible stool in the rectal vault or anus, along with complaints that she felt the need to have a bowel movement but could not pass stool. Progress notes also documented periods of no bowel movement for multiple days, including 5 days, 6 days, and 7 days without a bowel movement, as well as abdominal distention and firmness. During observation, the resident was unable to answer questions related to her bowel regimen, and a CNA stated the resident tends to have firm, hard stools. The facility’s bowel protocol and physician orders required Milk of Magnesia after 3 days without a bowel movement, followed by a Dulcolax suppository and then a phosphate enema if needed. Review of the bowel elimination record and MAR showed that bowel medications were given on some occasions, but the record reflected extended gaps without bowel movements and inconsistent timing in relation to the protocol. The DON validated concerns regarding noncompliance with the resident’s bowel protocol, including failure to initiate the protocol timely and failure to follow the protocol per facility policy.
Narcotic Reconciliation Not Followed for Fentanyl Patch Disposal
Penalty
Summary
The facility failed to consistently implement standards of practice and follow its policy and procedures for narcotic reconciliation for 1 of 6 medication carts. On 06/02/26 at 7:05 AM, review of the narcotic book for the Sunflower unit medication cart showed a Fentanyl Patch Proof of Use Form for the resident in room [ROOM NUMBER]-1, and the entries dated 05/22/26 at 10:04 AM and 05/31/26 at 1:00 PM each had only one nurse's signature. On 06/02/26 at 8:15 AM, the same form was reviewed again and the 05/31/26 1:00 PM entry now had two nurses' signatures. During interview, RN B stated she signed the form that morning for the resident in room [ROOM NUMBER]-1 and for the 05/31/26 entry without witnessing the destruction of the Fentanyl patch on 05/31/26. LPN C stated that signing a proof of use form for destruction of a Fentanyl patch without witnessing the destruction was not standard practice and was something she would never do. The facility policy for Narcotic Pain Patch stated that the used fentanyl patch would be disposed of by the nurse removing the patch and another nurse verifying the destruction of the patch.
Smoke Barrier Wall Penetrations Compromise Fire Resistance
Penalty
Summary
Surveyors observed that the facility failed to ensure smoke barriers were constructed to a minimum 1/2-hour fire resistance rating as required by code. Specifically, on April 29, 2025, wire bundle penetrations were found within the smoke barrier walls above the ceiling at the cross corridor doors in both the A wing and B wing. These penetrations were located within the electrical conduit and were confirmed by maintenance staff at the time of observation. The deficiency was identified as potentially affecting 17 occupants within the adjacent smoke compartment if smoke were to pass through these penetrations during a fire. No information regarding the medical history or condition of specific residents was provided in the report.
Plan Of Correction
On April 29th, 2025, the smoke compartments/smoke barriers on unit A and B were immediately repaired by the maintenance department. Maintenance personnel performed a thorough compliance check of all smoke barrier panels throughout the facility. The Maintenance Director has added monthly barrier penetration checks to the Maintenance Care work-order program. Reminders will be auto-generated by the program and documented through Maintenance Care upon completion. The Maintenance Personnel conducted a thorough compliance check of all smoke barrier penetrations throughout the facility to ensure safety and adherence to fire codes. Following this evaluation, the Maintenance Director has implemented a new procedure that incorporates monthly smoke barrier penetration checks into the Maintenance Care work-order program. This proactive approach involves regularly monitoring and assessing the integrity of smoke barriers, which are crucial for maintaining fire safety. As part of this initiative, reminders for these checks will be automatically generated by the Maintenance Care program. Each check completion will be documented within the system to maintain a comprehensive record of compliance and any necessary maintenance actions taken. Maintenance Personnel will conduct a weekly audit for 4 weeks, then monthly or until the home has reached substantial compliance. Results will be taken to QAPI. The Maintenance Director or designee is responsible for sustained compliance. Date of Compliance: June 16th, 2025
Hazardous Area Deficiency Due to In-Room Wheelchair Battery Charging
Penalty
Summary
A deficiency was identified when a wheel chair battery charger unit was observed in use within a resident's room in the F wing, specifically room #114. The battery was being charged during night hours inside the resident's room, as confirmed by maintenance staff during an interview. This practice failed to comply with requirements for hazardous areas, which mandate protection by a fire barrier with a 1-hour fire resistance rating or an automatic fire extinguishing system, as outlined in 8.7.1.1 and 19.3.5.9. The deficiency was noted based on direct observation and staff interview, with the potential to affect two occupants in the event of a hazardous gas release within the room.
Plan Of Correction
All electric wheelchair chargers have been systematically removed from residents' individual rooms and relocated to designated Life Enrichment rooms. This decision was made to enhance safety and ensure compliance with new protocols. A comprehensive policy and procedure document has been developed to outline the new charging process. All staff members have undergone extensive training regarding the proper protocol for transporting unoccupied electric wheelchairs to the Life Enrichment room for overnight charging. Charging in residents' rooms is now strictly prohibited to minimize potential hazards and disturbances. The Life Enrichment room is strategically chosen as the charging location since it remains unoccupied overnight, reducing any risks associated with electrical equipment being near residents during those hours. As part of the onboarding process, new residents will receive thorough education about this policy and procedure to ensure they fully understand the charging process and its importance for safety. Additionally, the maintenance personnel have been assigned to conduct a detailed inspection of the charging setup on a weekly basis for the first month. Following this initial period, inspections will transition to a monthly schedule for the subsequent three months, or until the facility demonstrates substantial compliance with the established policy. The results of these inspections, along with any findings, will be tracked and presented to the Quality Assurance and Performance Improvement (QAPI) committee for further evaluation and action, ensuring that ongoing compliance and safety standards are maintained. This structured approach aims to provide a safe environment for residents while effectively managing the charging of electric wheelchairs. The Maintenance Director or designee will be responsible for sustained compliance. Date of Compliance: 06/16/2025
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow policy and procedures, monitor, and assist Resident #18 (R18) in preventing accidents and hazards related to toileting. R18, who was severely cognitively impaired and required partial/moderate assistance with toilet transfers, was observed multiple times self-transferring to the toilet and performing other activities without supervision. Despite having a care plan that required substantial assistance, R18 was left unattended, and the call light was often out of reach, leading to multiple falls and incidents of incontinence without timely assistance from staff. The incident reports for R18 revealed a pattern of falls and inadequate supervision. On several occasions, R18 was found on the floor after attempting to self-transfer, often in the bathroom, and was incontinent. The care plan interventions, such as using a touch pad call light, encouraging toileting every two hours, and ensuring the call light was within reach, were not effectively implemented or monitored. Additionally, there was no documentation of when R18 was last toileted or offered toileting, and post-fall neurological checks were not consistently performed. Interviews with staff, including the Assistant Director of Nursing (ADON), indicated a lack of awareness of R18's current ambulatory status and an absence of a system to evaluate the effectiveness of interventions after a fall. The facility's policies on fall prevention and post-fall evaluations were not adequately followed, resulting in repeated falls and a failure to provide a safe environment for R18. The care plan interventions were not re-evaluated for effectiveness, and the resident's needs were not anticipated or met as required by the facility's protocols.
Failure to Label Insulin Pen
Penalty
Summary
The facility failed to ensure that an insulin pen was labeled with the resident's name for one of the two medication carts inspected. During an inspection of the C Wing Medication Cart, a previously used Humalog insulin pen without a resident's name on it was found in an unlabeled slotted compartment in the top drawer of the medication cart. The other insulin pens in the compartment were labeled with a resident's name. The LPN stated that insulin pens should be labeled with the resident's name, the date it was first used, and the discard date. She admitted that without the label, she would not know for sure which resident the insulin pen belonged to, especially since another resident also had a Humalog pen in the same cart. Further interviews with other nursing staff revealed that insulin pens typically come from the pharmacy with a label containing the resident's name. If an insulin pen is pulled from the medication back-up box, the staff is responsible for labeling it with the resident's name and the date it was opened. The staff members interviewed stated that if they found an insulin pen without a label, they would discard it because they would not know which resident it belonged to. The facility's policy on labeling medications and biologicals requires that all medications be labeled with the resident's name to ensure safe administration. The failure to label the insulin pen created a potential risk for residents to receive medication from another resident's pen, which could lead to the spread of disease.
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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 Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Fremont | 0.1 mi | ★★★★★ | 6 | 0 |
| Optalis Health & Rehabilitation Of Whitehall | 21.7 mi | ★★★★★ | 22 | 0 |
| Hillcrest Nursing And Rehabilitation Community | 21.8 mi | ★★★★★ | 12 | 0 |
| Christian Care Nursing Center | 22.1 mi | ★★★★★ | 10 | 0 |
| Lake Woods Nursing & Rehabilitation Center | 22.8 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.