Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oceana County Medical Care Facility during CMS and state inspections, most recent first.
A resident with severe cervical spinal stenosis and cord signal changes was admitted with instructions for urgent neurosurgery follow-up, but the consult was not documented until weeks later. After an unwitnessed fall and a rapid decline marked by hand numbness, tremors, ataxia, weakness, and loss of function, therapy and nursing notes showed worsening status while the resident remained in the facility. The resident was eventually sent to the hospital, where imaging showed severe C-spine stenosis and a large disc herniation, and spine surgery recommended ACDF.
Failure to Protect a Resident from Verbal Abuse: A CNA used profanity and disrespectful language toward a resident during evening care, telling her to stay on her “f***ing side” while another CNA witnessed the interaction. Staff also reported prior incidents of the CNA yelling at residents and using aggressive behavior, and the DON confirmed that abuse concerns had not been promptly reported.
Failure to Immediately Report Verbal Abuse: A CNA used profanity and disrespectful language toward a resident during care, and another CNA witnessed the abuse but did not report it immediately to the Abuse Prevention Coordinator. The DON confirmed staff delayed reporting for several days and also knew the CNA had been abusive to other residents previously, but those incidents were not reported.
A resident with depression and anxiety exited through the main entrance without staff, and a second resident with Alzheimer’s disease exited unsupervised through a fire exit door after alarms sounded and a door was found unlatched. The facility also failed to fully investigate a fall for a resident with severe cervical spinal stenosis; the incident report lacked a witness statement, management and family notification were not documented, and no root cause analysis was found in the record.
Multiple residents did not receive medications as ordered, and medication administration was inaccurately documented. Issues included missed doses of critical medications, discrepancies between medication removal logs and MARs, and failure to perform or document required pre-administration assessments such as blood pressure checks. These deficiencies were confirmed by facility leadership and were not in line with established policies or nursing standards.
A resident who was dependent on staff for transfers and required assistance was repeatedly left without access to a call light, despite care plan instructions. Staff interviews confirmed that the call light was not placed within reach after the resident was assisted back to the room, leaving the resident unable to request help when needed.
The facility failed to maintain adequate ventilation in the AU Unit and 200 Hallways, leading to stagnant, humid air and lingering odors in resident rooms and restrooms. Observations and interviews revealed that the ventilation system was not functioning properly, with restroom vents lacking suction and air return ducts having little to no air pressure. The Maintenance Director acknowledged a potential blower motor issue and the absence of a preventative maintenance checklist.
The facility failed to communicate residents' code status to their guardians or responsible parties in a timely manner and did not maintain copies of advanced directives in the medical records. A resident's POA was not informed of the code status until 1.5 months after the resident was deemed unable to make decisions. Another resident's POA was informed five months late, and a third resident's guardian was informed 27 days after appointment. The facility did not ensure advanced directives were obtained and maintained, risking residents' wishes not being honored.
Delayed response to worsening neurologic status and missed neurosurgical follow-up
Penalty
Summary
The facility failed to promptly identify and act on a change in condition for one resident with severe cervical spinal stenosis and cord signal changes. The resident was admitted with instructions from the hospital to arrange outpatient neurosurgery follow-up as soon as possible because of abnormal cervical spine MRI findings and risk for severe spinal cord injury with continued falls or cervical spine injuries. The record review showed no documentation that the neurosurgical consult was initiated upon admission, and the consult was not documented until 21 days after admission. After the resident reported a fall at the facility, the incident report documented bruising and pain, but it did not identify the staff member who assisted the resident from the floor or show that the fall had been immediately reported to the care team. Therapy documentation then showed a progressive decline in function, including increased imbalance, knee buckling, tremors, ataxic gait, posterior lean, decreased upper extremity function, numbness in both hands, inability to feed herself, and increasing dependence for transfers and mobility. Staff notes and physician communications documented ongoing numbness, weakness, loss of coordination, and worsening tremors over several days. The resident’s decline was discussed in interdisciplinary meetings, and therapy staff expressed concern that the resident’s condition was worsening, but the record showed no timely diagnostic workup or specialist evaluation until the resident’s condition had significantly deteriorated. A physician communication on 4/1/26 requested urgent neurology and/or neurosurgery evaluation and advanced imaging for acute neurologic change, and the resident was sent to the hospital that day. Hospital documentation later showed severe cervical spinal stenosis at C3-4 with a large central disc herniation and subtle spinal cord signal abnormality suspicious for myelopathy, and orthopedic spine surgery recommended ACDF at C3-4.
Failure to Protect a Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA. The resident was a female with multiple sclerosis who was admitted to the facility and required assistance with evening care. During care, the CNA used profanity toward the resident and told her to stay on her “f***ing side” while the resident was trying to reposition herself. Another CNA witnessed the interaction and reported that the language was inappropriate and disrespectful. The investigation also showed that staff had prior concerns about the CNA’s behavior toward residents. A witness stated the CNA was not very nice to residents, had yelled at the resident to stop moving, and had threatened to call the resident’s daughter if she did not stop. The witness also reported seeing the CNA act frustrated and make aggressive gestures while discussing a resident. The CNA’s employee file documented prior disciplinary actions for unprofessional conduct, including obscene or improper language and disorderly conduct, before the verbal abuse incident involving the resident. The DON confirmed that the witness delayed reporting the abuse for several days and that staff had not immediately reported the incident when it occurred. The DON also stated that staff had previously observed abusive behavior by the CNA toward other residents but did not report those incidents to the Abuse Prevention Coordinator. According to the DON, staff said they stopped reporting the CNA’s inappropriate behavior because management had not taken action on earlier allegations.
Failure to Immediately Report Verbal Abuse
Penalty
Summary
The facility failed to ensure staff immediately reported an allegation of verbal abuse to the abuse coordinator for one resident. The resident was a female admitted with multiple sclerosis. A Facility Reported Incident documented that on 5/30/26 a CNA used inappropriate language toward the resident during care, and another CNA later reported that the accused CNA directed profanity toward the resident while providing care. A witness statement from one CNA described the accused CNA telling the resident, "you need to stay on your f***ing side" and, "We go through this every f***ing night." Another witness stated that the CNA was not very nice to residents and that this had been reported in the past. The Director of Nursing confirmed that the CNA who witnessed the abuse waited 3 days to report it, and that staff did not follow the facility's abuse reporting process after observing the verbal abuse. The DON also stated that staff had known the accused CNA had been abusive to other residents previously and had failed to report those incidents to the Abuse Prevention Coordinator. According to the DON, staff reported they had stopped bringing forward the CNA's inappropriate behavior because management had not taken action after prior allegations. The report states that the expectation was for any observation, notification, or inclination of abuse to be immediately reported to the DON, who served as the Abuse Prevention Coordinator, or to the NHA.
Failure to Prevent Elopement and Complete Fall Investigation
Penalty
Summary
The facility failed to provide adequate supervision and ensure systems were in place to prevent the elopement of two residents. One resident with diagnoses including major depressive disorder and anxiety was determined to be a high wandering risk after previously being assessed as low risk. The resident exited through the main entrance without staff during a time when a vendor entered the facility and caused the doors to open. Staff reported the resident reached the driveway area near a busy parking lot and a high-traffic roadway before being brought back inside. The record contained no documentation of the unsupervised exit, no incident report, and no documented rationale for the new roam alert ankle monitor or the change in wandering risk status. A second resident with Alzheimer’s disease and dementia with mood disturbances had been identified as high risk for wandering and elopement. The record showed repeated wandering behaviors, including attempts to go through doors and setting off alarms. On one occasion, the resident exited unsupervised through a fire exit door and was found outdoors in the facility’s enclosed courtyard. A witness statement described an alarm sounding at the garden hallway door, the door being found not latched, and the resident later being observed outside in a wheelchair. During observation, facility leadership confirmed that the courtyard gates were latched but not locked, and that the fire doors did not have roam alert alarms, although one door had a functioning alarm that sounded when opened. The facility also failed to operationalize its fall policy for a resident with severe cervical spinal stenosis. The resident reported that she fell while transferring from a wheelchair to a recliner and slid to the floor, then got partway back into the recliner with staff assistance. The incident report did not include a witness statement from the staff member who assisted her, did not document notification to management or the resident’s emergency contacts, and the electronic record contained no documentation of a witness statement or root cause analysis. The resident’s records also included physician communication stating she was at risk for more significant cord injury with continued falls, and the family member reported she had not been notified of the fall.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with physician orders and that medication administration was accurately documented for six out of seven residents reviewed. For one resident with a history of kidney transplant, the anti-rejection medication Tacrolimus was not administered on multiple occasions due to confusion over medication packaging and discrepancies in the medication cart. The nurse responsible signed the Medication Administration Record (MAR) as if the medication had been given, despite not administering it, which was later substantiated by low Tacrolimus levels in the resident. Other residents experienced similar issues with medication administration and documentation. One resident with quadriplegia did not have a controlled substance (Valium) properly documented as removed from the medication card, even though the MAR indicated it was administered, and there was no documentation for withholding the dose. Another resident with dementia had a dose of Ativan not documented as removed from the medication card, while the MAR showed it was given, with no supporting documentation for withholding. A resident with chronic pain was prescribed two tablets of Tramadol at bedtime, but only one tablet was documented as removed on several occasions, while the MAR reflected administration of two tablets, and there was no documentation for dose changes or omissions. Additionally, residents prescribed medications requiring pre-administration assessments, such as blood pressure checks for antihypertensive and orthostatic hypotension medications, did not consistently have these assessments performed or documented. In several instances, blood pressure readings from previous times or days were used to justify medication administration, or medications were held without documentation of the required assessment or rationale. These failures were confirmed by facility leadership and were not in accordance with facility policy or professional standards of nursing practice.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a dependent resident's call light was consistently left within reach, as required by the resident's care plan. The resident, who had diagnoses including diabetes, heart failure, and weakness, was dependent on staff for transfers and required the call light to be accessible when alone in the room. On multiple occasions, the resident was observed sitting in a recliner with the call light either out of reach or not visible, and the resident reported being unable to locate or use the call light to request assistance. Interviews with staff confirmed that the call light should have been left within the resident's reach after being assisted back to the room, but this was not done. One CNA acknowledged forgetting to place the call light within reach after assisting the resident, and another confirmed the resident's need for staff assistance and the importance of call light accessibility. These actions and inactions resulted in the resident being unable to call for help as directed by the care plan.
Ventilation Deficiency in AU Unit and 200 Hallways
Penalty
Summary
The facility failed to maintain adequate ventilation in the AU Unit and the 200 Hallways, resulting in stagnant, muggy, and humid air, as well as lingering odors in resident rooms and restrooms. Observations on multiple occasions revealed that the air in the halls and resident rooms felt stagnant, with some rooms having persistent bathroom odors. Family members also reported that the rooms were consistently hot and stagnant, indicating a chronic issue with the ventilation system. Further investigation by maintenance personnel confirmed that the restroom vents in several rooms were not producing any suction, and the air return ducts in various rooms had little to no air pressure. The Maintenance Director acknowledged a potential issue with the blower motor on the unit and noted the absence of a preventative maintenance checklist. Despite checking the roof, no visible problems with the ventilation system were identified, suggesting an unresolved issue affecting the air quality in the facility.
Failure to Communicate Code Status and Maintain Advanced Directives
Penalty
Summary
The facility failed to provide timely communication of residents' code status to their designated guardians or responsible parties and did not maintain copies of advanced directives in the medical records for several residents. For Resident #32, the facility did not have documentation of the resident's advanced directives for medical decisions in the medical record, despite the resident being deemed unable to make medical decisions. The responsible party, identified as the power of attorney (POA) for medical care, was not informed of the resident's code status until 1.5 months after the resident was determined to be unable to make medical decisions. The facility's Director of Nursing (DON) and Social Worker (SW) attempted to obtain the necessary documentation from the responsible party, but it was not provided by the time of the survey. Resident #64 also lacked documentation of advanced directives for medical decisions in the medical record, and the responsible party was not informed of the resident's code status until approximately five months after the resident was determined to be unable to make medical decisions. The facility eventually received a document designating the responsible party as the patient advocate, but this was only added to the medical record on the day of the survey. For Resident #76, the facility did not document that the resident's guardian was informed of the resident's Do Not Resuscitate (DNR) wishes until 27 days after the guardian was appointed. The facility's policy required that residents or their representatives provide advanced directives at the time of admission, but the facility failed to ensure these documents were obtained and maintained in the residents' medical records, leading to the potential for residents' wishes not being honored.
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 45 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 Hart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Medical Care Facility | 18.1 mi | ★★★★★ | 9 | 0 |
| Medilodge Of Ludington | 18.4 mi | ★★★★★ | 14 | 0 |
| Optalis Health & Rehabilitation Of Whitehall | 21 mi | ★★★★★ | 22 | 0 |
| Regency At Fremont | 27.4 mi | ★★★★★ | 13 | 0 |
| Newaygo Co Medical Care Facility | 27.5 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oceana County Medical Care Facility.
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 October 2026) and official state health department websites.