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 Sanilac Medical Care Facility during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe cognitive impairment, muscle weakness, and a prior right tibia fracture required dependent assistance for transfers and had a care plan specifying use of a Hoyer lift with a red-trim sling and an assist of one. On one morning, a CNA instead performed a two-person manual transfer of the resident into a personal wheelchair, deviating from the written transfer plan despite having been trained on it. Later that morning, the resident complained of right lower extremity pain with deformity, and imaging showed acute displaced fractures of the distal tibia. Subsequent observations and staff interviews confirmed that mechanical lifts and correctly colored slings were readily available and that staff were expected to follow the transfer instructions posted in the resident’s closet, indicating the deficiency arose from failure to follow the individualized plan of care during the transfer.
Improper Sanitizer Concentration in Kitchen: During kitchen observations, the rag sanitizer bucket tested at zero with quaternary ammonia strips, then later tested between 150-200 ppm after being changed out. The CDM stated the desired range was 50-100 ppm and said the bucket was changed each morning and evening shift. Record review showed the sanitizer product label required 150 ppm for sanitizing food contact surfaces, and the Food Code requires use according to EPA-registered label instructions.
Water system cleanliness and backflow prevention deficiencies were observed during an environmental tour. A water softener brine tank in the boiler room contained black foam, and staff stated the tank is cleaned every three years and that cleaning was due. Surveyors also observed a water softener drain line sitting inside a drain, and in two custodial closets, hoses and attachments were connected downstream of AVBs without the noted proper configuration.
Staffing shortages led to repeated delays in resident care, including long call light response times, missed restorative services, and cancelled activities. Residents reported waits of 30 minutes to over an hour for assistance, one resident was still waiting for morning care and hygiene before a care conference, and another had restorative therapy interrupted because the aide was pulled to the floor. Staff and residents described heavy CNA assignments, frequent mandation, loss of CNAs, and activity staff being pulled away from their duties.
A resident with significant cognitive and psychiatric needs was subjected to verbal abuse by a CNA, who called the resident 'crazy' and made other derogatory remarks in the presence of the resident and others. The incident was witnessed by another CNA, and the resident expressed distress and refused care as a result. The resident's care plan required a non-confrontational environment, which was not maintained during the incident.
PASARR screening was not completed for a resident with diagnoses including TBI, anxiety, mood disorder, dementia, and impaired decision-making. The resident’s record showed a PASARR Level I screen with positive mental illness criteria, but it lacked a DCH-3878 exemption request, Level II documentation, and CMHSP communication. SS reported PASARR was not being done for the facility, and the DON stated there was no PASARR information for the following year and no health department letter could be found.
A resident with dementia, anxiety, and depressed mood did not have Lexapro available for about three weeks, yet the MAR showed doses as given even though the medication was not in the cart or backup supply. Staff said the resident’s daughter ordered the drug through an outside pharmacy, the prescription had no refills, and nurses were still charting administration despite the medication being unavailable.
A facility failed to provide ordered restorative therapy for two residents with limited ROM and mobility needs. One resident with weakness and difficulty walking was supposed to receive active ROM, standing, and a walking program, but staff only walked the resident short distances in the room and restorative records showed missed sessions. Another resident with paraplegia and intact cognition reported not receiving PROM for 2 weeks and feared her legs were getting stiff; the restorative nurse confirmed therapy was inconsistent because the aide was pulled to the floor and could not cover the building.
A resident with an indwelling urinary catheter, moderate cognitive impairment, and dependence for ADLs was observed with the catheter privacy bag and tubing in contact with the floor while seated in a wheelchair and while being transported by staff through the dining area and hallway. Staff continued moving the resident without adjusting the bag or tubing, and the ICP later confirmed they should not touch the floor; the facility policy also stated privacy bags are not to be in direct contact with the floor.
A resident developed an unstageable pressure ulcer due to the facility's failure to ensure comprehensive documentation and evaluation. The resident, with multiple diagnoses, was admitted with a stage 4 pressure ulcer. Upon readmission, the coccyx/sacrum area was initially documented as MASD, but inconsistent monitoring led to the development of a large necrotic unstageable ulcer. The facility's policies on skin inspection and wound care were not adequately followed, contributing to the deficiency.
Two residents in a LTC facility sustained injuries due to staff failing to follow prescribed transfer protocols. One resident, with a history of stroke and weakness, suffered foot fractures during a transfer when only one staff member assisted instead of the required two. Another resident, with a history of femur fracture, was lowered to the floor by a single CNA, contrary to the care plan requiring two-person assistance, resulting in pain and a decline in transfer status.
A facility failed to administer a nebulizer treatment according to standards, as a nurse did not assess or monitor a resident during treatment. Additionally, two residents did not receive medications as prescribed, with one not receiving an inhaler and medications given late. Another resident was prescribed multiple psychotropic medications without proper consent or documentation of non-pharmacological interventions.
The facility failed to implement a comprehensive infection control program, lacking hand hygiene supplies and proper practices. Staff were observed not performing hand hygiene, and infection control audits were inadequately documented. Residents with ongoing infections were not properly monitored, and catheter care was substandard, increasing infection risk.
The facility failed to obtain informed consent before initiating antipsychotic medication for two residents with severe cognitive impairment. One resident was started on Seroquel and Clonazepam without proper documentation or consent, while another was given Ativan without prior notification to the responsible party. The facility's policy requires education on risks and benefits and obtaining consent, which was not followed.
A facility failed to respect a resident's choice in guardianship, leading to distress for the resident. The resident, who requires assistance with all care, was upset because the facility initiated legal action to remove her sister as her guardian due to unpaid expenses after a Medicaid eligibility issue. The facility did not effectively communicate with the resident or her guardian, leading to confusion and distress. The facility's actions were not aligned with the resident's rights to self-determination and choice.
The facility failed to update care plans for residents with severe cognitive impairments who experienced multiple falls and infections. A resident with a history of traumatic brain injury and paraplegia had repeated falls and hospitalizations for UTIs, but care plans lacked new interventions. Another resident with Alzheimer's disease had falls without proper care plan updates or implementation of interventions. A third resident with dementia had falls without appropriate care plan revisions, and some interventions were inappropriate. The facility's policy for incident investigation and intervention implementation was not consistently followed.
A resident with multiple medical conditions, including a Stage 4 sacral pressure ulcer and an amputation, was found with long, soiled fingernails and cracked toenails due to the facility's failure to provide routine nail care. The resident, who required substantial assistance with hygiene, reported that staff had not trimmed her nails in a while, and her care plan did not specifically address nail care.
A facility failed to administer oxygen per physician's order and did not store nebulizer equipment sanitarily for a resident with respiratory needs. The resident's oxygen concentrator was set to 5 liters per minute instead of the ordered 6 liters, and the nebulizer mask was improperly stored. The resident had diagnoses including COPD, Stroke, and CHF, requiring assistance with all ADLs.
A facility failed to coordinate dialysis care for a resident with multiple health issues, including chronic kidney disease and dialysis dependence. The Hemodialysis Communication Forms often lacked information on the dialysis access site and post-dialysis instructions. The facility's records did not mention the dialysis access site, and nurses failed to document the required post-dialysis site assessment. The Director of Nursing acknowledged these documentation and assessment deficiencies.
A facility experienced a 26.19% medication error rate due to omitted and delayed medication administration for two residents. A nurse failed to administer Protonix and Symbicort inhaler to a resident, while another resident received several medications late. The Clinical Supervisor cited resident preferences and workload as contributing factors.
A nurse improperly stored medications, including a narcotic, during administration. Medications were placed in a cup and left in the medication cart drawer, including an inhaler and Lyrica, a controlled substance. The nurse was unaware of the facility's policy on medication storage, and the DON confirmed that narcotics should be stored under two locks.
The facility failed to implement a comprehensive antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident with multiple health issues received various antibiotics without effective monitoring, resulting in a multi-drug resistant organism. Another resident continued antibiotic treatment despite a negative culture result. The facility did not adhere to its policies on infection control and antimicrobial stewardship, lacking oversight and communication with providers.
A facility failed to assess and monitor a resident's hydration status, resulting in undocumented IV fluid administration and no family notification. The resident, with a history of Diabetes Type 2 and Chronic Kidney Disease, had high sodium levels indicating dehydration. Despite orders for a saline bolus, there was no record of the amount administered before the resident removed the IV. The DON confirmed the lack of documentation and family notification, leading to the resident's hospital admission for Hypernatremia.
A resident with early onset Alzheimer's was admitted to a facility without psychotropic medications but was later prescribed multiple such drugs without baseline testing or monitoring. The resident's health declined, leading to decreased liver and kidney function, and he was hospitalized multiple times before passing away. The facility failed to provide adequate education and consent about the medications' risks, contributing to the resident's decline.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Tibia Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety by not following care-planned interventions during a transfer to a wheelchair. A resident with Alzheimer’s disease, muscle wasting and atrophy, muscle weakness, need for assistance with personal care, and a right tibia fracture was admitted and later readmitted to the facility. The resident’s Minimum Data Set showed severely impaired cognition with a Brief Interview of Mental Status score of 0/15, and dependence on staff for transfers, bathing, dressing, and personal hygiene. The resident’s individualized plan of care required use of a mechanical lift (Hoyer lift) with a red-trim sling for transfers, with an assist of one person at the time of the incident. On the morning in question, a CNA reported assisting the resident into her personal wheelchair prior to 6:00 AM using a two-person manual transfer instead of the required mechanical lift with the red-trim sling. This action deviated from the resident’s individualized plan of care, which clearly specified use of the Hoyer lift and sling, and the CNA had been appropriately trained on this requirement. The CNA could not recall who assisted with the transfer and reported that the resident did not complain of pain and that no accident or injury occurred at that time. The evening before, the resident had been transferred back to bed by a CNA and a nurse, and the sling used for that transfer had been soiled and sent to the laundry. Later, at approximately 8:30 AM, staff notified the DON that the resident was complaining of pain in the right lower extremity, with deformity noted, and no fall, accident, or injury had been witnessed or reported. Diagnostic imaging at the hospital revealed an acute comminuted mildly displaced fracture of the distal tibial metadiaphysis and an acute mildly displaced fracture of the distal tibial diaphysis. Subsequent observations during the survey showed the resident sitting in a wheelchair with the right leg elevated in a cast and a red-trim mechanical lift sling positioned underneath her, with a mechanical lift available in the hallway. Interviews with laundry and CNA staff confirmed that there were sufficient mechanical lifts and appropriately colored slings available, and that staff were aware that transfer requirements were listed in the resident’s closet care plan. The facility’s failure occurred when the CNA did not follow the resident’s established transfer plan of care and used a manual transfer instead of the required mechanical lift and sling.
Improper Sanitizer Concentration in Kitchen
Penalty
Summary
The facility failed to maintain best practices in the kitchen when the rag sanitizer bucket did not contain the proper quaternary ammonia concentration during survey observations. On 08/19/2025 at 8:45 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), the sanitizer bucket was tested with Hydrion quaternary ammonia test strips and the result was zero. The CDM changed out the bucket and retested it, and the second result was between 150-200 ppm. On 08/20/2025 at 9:03 AM, the rag sanitizer bucket was retested and again showed a result of zero. During interview, the CDM stated the desired concentration range for the sanitizer was 50-100 ppm and said the bucket was changed every morning and evening shift, then instructed dishwashing staff to change out the bucket. Record review of the sanitizer product with EPA Reg No. 10324-81 showed the label instructions required 150 ppm for sanitization of food contact surfaces, and the 2022 Food Code states chemical sanitizers must be used in accordance with the EPA-registered label instructions.
Water System Cleanliness and Backflow Prevention Deficiencies
Penalty
Summary
The facility failed to ensure cleanliness of the water system and the use of appropriate backflow prevention on cross connections. During the environmental tour with the Director of Operations K and Maintenance Assistants L and M, the water softener brine tank in the main boiler room was observed filled with a black foam substance. Maintenance Assistant L stated that the brine tank is cleaned out every three years and that the cleaning was due. Additional observations in the boiler room in the 800 hallway found black foam inside the water softener brine tank and the drain line to the water softener sitting inside the drain. In the custodial closet in the 600 hallway, a chemical dispenser was connected to a utility sink by a hose downstream of an atmospheric vacuum breaker without an attached wasting tee. In the 700 hallway custodial closet, a spray nozzle was attached to a hose connected to a utility sink downstream of an atmospheric vacuum breaker.
Staffing Shortages Led to Delayed Care and Long Call Light Waits
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and to have a licensed nurse in charge on each shift, resulting in long call light wait times, cancelled activities, and delayed resident care. During a resident council meeting, residents reported repeated waits of 26 to 49 minutes for call lights to be answered, with one resident describing being in pain and in tears while waiting. The resident council notes for the prior 6 months also reflected complaints of long call light response times in April 2025 and August 2025. Multiple residents described delays in care tied to staffing shortages. One resident reported waiting all morning for morning care and fresh clothing before a care conference, and observations showed whitish debris on the teeth and tongue and dried flaking debris on the face. CNAs stated that the hall had many residents needing two-person assistance and that the assignment was very heavy for only two CNAs, with a float CNA needed to help. Another resident reported concern that restorative therapy had not been provided for 2 weeks, stating staff who performed the exercises were pulled to the floor and no one else was available to complete the program. Documentation reviewed for that resident showed the restorative program was ordered 3 to 5 times per week, but the record reflected only limited days completed over the reviewed periods. Additional residents reported long waits for call lights, including waits over an hour, and one resident stated that staff were too busy and more staff were needed. A confidential staff member stated that residents who are not capable of using the call light do not get care timely on a consistent basis. A confidential resident advocate reported waits of 30 minutes to an hour with incontinent episodes while waiting for bathroom assistance. Activity staff reported being pulled to the floor repeatedly, including multiple days in August and July, and stated that on one weekend all activities were unable to be held because staff were pulled away. Scheduler and other staff reported daily mandation, recent loss of approximately 20 CNAs, frequent pulling of float staff to regular assignments, and burnout from working so many hours.
Failure to Prevent Verbal Abuse of Resident by CNA
Penalty
Summary
A deficiency occurred when a resident, who had a history of stroke, dysphagia, adjustment disorder with anxiety, and major depressive disorder, and who required assistance with all activities of daily living and was deemed incompetent to make medical decisions, was subjected to verbal abuse by a certified nursing assistant (CNA). The resident reported to surveyors that a staff member had laughed at their grandmother and expressed feelings that the staff member was antagonistic towards them. During care, the resident refused assistance from the CNA in question, and another CNA witnessed the accused CNA responding by calling the resident 'crazy' and slamming the bathroom door. The same CNA was later overheard in the dining room loudly making derogatory remarks about the resident, referring to them as 'crazy' and making other disparaging comments within earshot of the resident and others. The incident was corroborated by a witness who provided reassurance to the resident after the verbal exchange. The accused CNA admitted to venting loudly in the dining room but denied using specific derogatory terms in the resident's room. The resident's care plan included the need for a non-confrontational environment due to their psychiatric conditions, but this was not upheld during the incident. The events led to the resident refusing care and expressing distress, with the situation escalating to the point where the CNA left employment after being informed of the abuse allegation.
PASARR Screening Not Completed
Penalty
Summary
PASARR screening requirements were not completed for one resident reviewed for PASARR evaluation. The resident had a history that included traumatic brain injury, anxiety, mood disorder, mental disorder due to known physiological condition, dementia, and need for assistance with personal care. The MDS showed severely impaired cognitive skills for daily decision making and dependence on a helper for activities of daily living and mobility. A PASARR Level I Screening form dated 10/12/2023 showed “Yes” responses to screening criteria indicating a current diagnosis of mental illness, treatment for mental illness, and presenting evidence of mental illness or dementia, with documentation noting anxiety, mood disorder, and Buspar use. The resident’s record did not contain a DCH-3878 exemption request, information showing that a Level II screen had been completed, or communication from CMHSP. The form directions stated that if any answer to items 1-6 in Section II is Yes, one copy is to be sent to the local CMHSP, with a copy of form DCH-3878 if an exemption is requested, and the facility is to retain the original in the record and provide a copy to the patient or legal representative. During interview, SS Q stated PASARR was not being done for the facility and that the DON would have the PASARR forms. The DON stated the last PASARR was done in October 2023, that there was nothing for 2024, that a letter from the health department could not be found for 2023, and that there were problems accessing the website to generate the letters.
Lexapro Unavailable and Incorrectly Documented
Penalty
Summary
The facility failed to ensure the availability and accurate documentation of Lexapro for a resident admitted with diagnoses including dementia, hyperlipidemia, hypertension, adjustment disorder with mixed anxiety and depressed mood, and anxiety. The physician order was for Lexapro 5 mg by mouth daily for agitation, irritability, and depressed mood, but review of the August 2025 MAR showed the medication was documented as administered 10 times out of 20 days reviewed even though the resident did not have Lexapro available for the facility to give, and the MAR documentation was described as erroneous. Record review and staff interviews showed the resident had no Lexapro available for approximately three weeks. Progress notes documented that the pharmacy said the prescription needed renewal, that there had been no Lexapro for at least two weeks, and that the last order had been filled in December 2024 with no refill request since then. Staff reported the resident’s daughter handled ordering through the outside pharmacy, which shipped the medication to the daughter for delivery to the facility. The Clinical Care Coordinator stated nurses had been charting Lexapro administration despite the medication not being available, and the DON stated the inaccurate documentation should not have occurred.
Failure to Provide Ordered Restorative Therapy
Penalty
Summary
The facility failed to ensure restorative therapy services were provided as ordered for two residents with limited ROM and mobility needs. Resident #36 was admitted with diagnoses including muscle weakness, difficulty walking, and need for assistance with personal care, and required assistance with all ADLs with intact cognition. The physician orders and care plan included active ROM exercises, static standing, and a walking program, but interviews with CNAs and the restorative nurse showed the resident was only walked short distances in the room to the bathroom rather than the ordered hallway ambulation, and restorative documentation showed missed or blank entries for multiple days. The restorative nurse stated the resident only had one day of restorative therapy and that the restorative CNA was pulled to the floor for resident care and could not provide the ordered services. Resident #50 was admitted with incomplete paraplegia, spinal cord disease, cervical disk disorder with myelopathy, reduced mobility, muscle weakness, and need for assistance with personal care. The MDS showed intact cognition and dependence for toileting, personal hygiene, bathing, dressing, transfers, and rolling. The resident reported concern that her legs were getting stiff and stated she had not received restorative therapy for 2 weeks, explaining that the staff member who performed the exercises had been pulled to the floor and no one else was available to do them. The restorative nurse confirmed the resident was ordered PROM for both upper and lower extremities, but the last documented restorative therapy available was from 8/9/25, and the nurse stated the aide could not cover the whole building when working the floor. Record review and staff interviews showed the restorative program was not consistently delivered for either resident despite active orders and documented need. For Resident #36, the restorative nurse acknowledged the resident did not receive restorative therapy during the first week reviewed and had limited completion during the second week because the restorative CNA was reassigned to resident care. For Resident #50, the restorative nurse stated the resident was off the plan at one point and later re-added, but the available documentation showed only intermittent days marked as completed, with missed restorative sessions attributed to staffing shortages and the restorative aide being pulled to the floor.
Catheter Bag and Tubing Left on Floor During Transport and While Seated
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter bag and tubing were kept off the floor for a resident admitted with diagnoses including diabetes, a Stage IV sacral pressure ulcer, need for assistance with personal care, and dementia. The resident’s MDS showed a BIMS score of 8/15, indicating moderately impaired cognition, and the resident was dependent on a helper for activities of daily living, transfers, and mobility. The resident had an indwelling urinary catheter. During observations in the dining room and hallway, the resident was seated in a wheelchair with the catheter bag inside a privacy bag positioned underneath the wheelchair and laying on the floor. As staff pushed the resident from the dining area through the hallway to the resident’s room, the bag was dragging on the ground and could be heard dragging on the floor, and staff did not stop to adjust the catheter bag or tubing. A later observation showed the catheter privacy bag partially lying on the floor and the catheter tubing lying on the floor while the resident was seated in the wheelchair in the room. The Infection Control Preventionist stated that the tubing and bag should not touch the floor and adjusted them after the observation. The facility policy stated that privacy bags are not to be in direct contact with the floor.
Failure to Prevent and Document Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure comprehensive documentation and evaluation to prevent the development of an unstageable facility-acquired pressure ulcer for a resident. The resident, who was alert and oriented, was admitted with multiple diagnoses including chronic osteomyelitis, diabetes, and a stage 4 pressure ulcer of the sacral region. Upon readmission, the resident's coccyx/sacrum area was initially documented as moisture-associated skin damage (MASD), but there was no consistent, ongoing assessment or monitoring of the area, leading to the development of an unstageable pressure ulcer. The resident's medical records revealed that the coccyx/sacrum area was not documented on the initial nursing admission assessment, and the order for barrier cream was delayed. Progress notes indicated the area became open with slough and necrotic tissue, eventually developing into a large necrotic unstageable pressure ulcer. The wound was not consistently measured, and there were discrepancies in documentation regarding the wound's status and treatment. Interviews with the wound nurse and nurse practitioner confirmed that the wound began at the facility. The resident reported difficulty turning in bed and prolonged sitting in a recliner, which contributed to the wound's development. The facility's policies on skin inspection and wound care were not adequately followed, as new wounds were not measured within the required timeframe, and there was a lack of documentation on wound progress and treatment plans.
Failure to Follow Transfer Protocols Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure appropriate interventions and supervision were in place to prevent falls with injury for two residents. Resident #44, who had a history of stroke and right-sided weakness, sustained fractures in her right foot during a transfer. The resident was supposed to be assisted by two staff members during transfers, but only one staff member assisted her, leading to her foot not being positioned correctly on a twist board, resulting in fractures. The resident experienced pain and required pain medication and an orthopedic consultation, which led to the use of an electronic lift for transfers. Resident #38, who had a history of a right femur fracture and other mobility issues, was also involved in an incident where the plan of care was not followed. The resident required a two-person assist with a rolling walker for transfers, but was assisted by only one CNA, resulting in the resident being lowered to the floor after slipping. The resident complained of pain in the right knee and leg, and x-rays were conducted to rule out a fracture. The incident led to a decline in the resident's transfer status, necessitating the use of a Hoyer lift. Both incidents highlight a failure to adhere to the residents' care plans, which required two-person assistance during transfers. The CNAs involved did not follow the prescribed care plans, leading to injuries and a decline in the residents' mobility status. The facility's investigation revealed that the staff did not provide the necessary assistance, and the CNAs involved were reprimanded or suspended pending further investigation.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer a nebulizer treatment according to professional standards for a resident, as observed during a survey. The nurse prepared the nebulizer treatment for the resident but did not assess the resident's lung sounds or vital signs before administration, nor did she monitor the resident during the treatment. The nurse left the room, and a CNA later discontinued the treatment without informing the nurse. The nebulizer equipment was not properly cleaned or stored, contrary to the facility's policy. Another deficiency involved the administration of medications as prescribed by the physician for two residents. One resident did not receive their inhaler during the medication pass, and the medication was given late. The nurse admitted to starting late and not administering the inhaler, which was left in the medication cart. The facility's clinical supervisor acknowledged that medications should be administered within a two-hour window, but this was not always feasible due to workload. The facility also failed to ensure appropriate diagnosis and use of multiple psychotropic and antipsychotic medications for another resident. The resident was admitted with dementia-related diagnoses and was not on any psychotropic medications initially. However, multiple antipsychotic medications were initiated at the facility without proper informed consent or documentation of non-pharmacological interventions. The resident's behaviors were not consistently documented, and the facility's social services director could not provide a timeline of interventions or explain the rationale for multiple medications.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection control program, as evidenced by the lack of hand hygiene supplies and inadequate hand hygiene practices. During a tour of the facility, it was observed that there were no hand sanitizer dispensers in the 400-hallway or resident rooms. Staff members were seen entering and exiting resident rooms without performing hand hygiene, and one staff member donned gloves without washing hands. Interviews with residents confirmed that staff did not consistently wash their hands before or after providing care. The facility's infection control program was found to be lacking in process surveillance and data monitoring. The Infection Control Licensed Practical Nurse (LPN) admitted that hand hygiene audits were not properly documented, and there was no process in place for tracking residents with potential infections who were not receiving antibiotics. The facility's Infection Control Committee had not met since the LPN started, and infection control data was only summarized in Quality Assurance meetings without further discussion or analysis. Specific residents were identified with ongoing infections and inadequate infection control practices. One resident with a history of urinary tract infections was found to have a multi-drug resistant organism in their urine. Another resident with a diabetic ulcer did not have access to hand sanitizer near their personal protective equipment. Additionally, catheter care was not performed according to professional standards, with catheter bags being placed directly on the floor. These deficiencies highlight the facility's failure to maintain effective infection prevention and control measures, increasing the risk of infection spread among residents.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to initiating antipsychotic medication for two residents, resulting in the residents and/or their responsible parties not being informed of the risks versus benefits of the medication use before initiation. Resident #25, who has severe cognitive impairment, was started on Seroquel upon admission without documentation of informed consent. Additionally, Clonazepam was initiated for 14 days without any progress notes or assessments, and no consent was present for this medication. Although consents for Seroquel and Paroxetine were eventually obtained, they were dated a week after the resident's admission. Resident #32, also with severe cognitive impairment, was started on Ativan for anxiety without prior notification to the responsible party or the resident. The consent form for Ativan was signed five days after the medication was initiated. An interview with the Director of Nursing confirmed that responsible parties should be informed prior to the initiation of psychotropic medication, and it was noted that the facility had been educating nursing staff to ensure families are informed and documentation is completed. The facility's policy on the use of psychotropic medications requires that residents and/or representatives be educated on the risks and benefits, and the appropriate party sign the consent regarding the medication being given.
Facility Fails to Respect Resident's Guardianship Choice
Penalty
Summary
The facility failed to accommodate a resident's choice in guardianship, leading to distress for the resident. Resident #16, who has full cognitive abilities and requires assistance with all care, was upset because the facility initiated legal action to remove her sister as her guardian and replace her with a public guardian. This action was taken after the resident lost Medicaid eligibility due to excess funds in her account, which occurred when a waiver for Medicaid eligibility expired. The resident's sister, who had been her guardian since 2019, was attempting to purchase a handicap-accessible van for the resident, which contributed to the excess funds. The facility's billing department did not inform the resident or her guardian about the Medicaid ineligibility until three months after it was denied. The guardian made payments towards the outstanding bill, and Medicaid eligibility was eventually restored. However, the facility proceeded with court actions to change the conservatorship due to the unpaid expenses. The facility's interim administrator and billing staff did not communicate effectively with the resident or her guardian about the court proceedings, leading to confusion and distress for the resident, who feared losing her sister as her healthcare guardian. Court documents revealed that the facility requested a specific person to be appointed as the conservator, and the resident's guardian felt blindsided by the facility's actions. The guardian stated that the facility did not adequately communicate the billing issues and that they were attempting to remove her from both conservatorship and guardianship roles. The facility's actions were not aligned with the resident's rights to self-determination and choice, as outlined in the CMS Nursing Home Toolkit, which emphasizes the importance of dignity, respect, and participation in care decisions.
Failure to Update Care Plans for Residents with Falls and Infections
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect changing care needs for three residents, resulting in the potential for unmet care needs. Resident #2, who has a history of traumatic brain injury, paraplegia, and severe cognitive dysfunction, experienced multiple falls and hospitalizations due to urinary tract infections. Despite these incidents, the care plans were not updated with new interventions to prevent future falls or address the recurring infections effectively. The care plan for falls had not been revised since 2022, and there was no mention of fall mats or resident alarms, even after multiple falls. Resident #6, diagnosed with Alzheimer's disease and severe cognitive impairment, also experienced several falls without appropriate updates to their care plan. The care plan interventions were not consistently implemented, as observed when the wheelchair was not positioned as required to facilitate safe transfers. The care plan was last updated in June 2024, but it did not reflect interventions for falls that occurred in May 2024. The Director of Nursing confirmed that fall interventions were not in place as required. Resident #32, with severe cognitive impairment and a history of falls, had multiple falls since admission, but the care plans were not updated with appropriate interventions. The interventions listed in the incident reports were not always reflected in the care plans, and some interventions were deemed inappropriate by the Director of Nursing. The facility's policy requires the restorative nurse or designee to investigate incidents and implement additional interventions, but this was not consistently done, leading to deficiencies in care planning and fall prevention.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide routine nail care for a resident, resulting in the resident having long, soiled fingernails and long, cracked toenails. During an observation, the resident expressed that she was unable to trim her nails herself and that her granddaughter had attempted to trim some of her toenails but was unable to do so completely due to their length and difficulty. The resident reported that the staff had not assisted her with nail care for some time. The resident's medical history includes kidney failure, right above the knee amputation, a Stage 4 sacral pressure ulcer, weakness, depression, intestinal fistula, colostomy, pulmonary hypertension, and atrial fibrillation. The resident was assessed to have full cognitive abilities and required substantial assistance with hygiene care. The care plan for the resident included interventions for skin integrity and hygiene but did not specifically address nail care. The Director of Nursing acknowledged that nail care should be provided with the resident's shower and mentioned that only nurses or podiatry could assist if the resident was diabetic.
Oxygen Administration and Equipment Storage Deficiency
Penalty
Summary
The facility failed to provide oxygen per the physician's order and did not store nebulizer equipment sanitarily for a resident with respiratory needs. On June 25, 2024, it was observed that the resident's oxygen concentrator was set to 5 liters per minute, despite the physician's order specifying 6 liters per minute. Additionally, the resident's nebulizer mask was found lying face down on the nightstand, which is not a sanitary storage practice. The resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Stroke, and Congestive Heart Failure, required assistance with all Activities of Daily Living and had intact cognition. Further observations on June 27, 2024, confirmed that the oxygen concentrator was still set to 5 liters per minute. An interview with Education Nurse C revealed that the concentrator could not deliver the ordered 6 liters, although the facility had the capability to provide the correct dosage. Subsequently, the physician's order was updated to reflect the 5-liter setting. This deficiency in providing the correct oxygen dosage and improper storage of nebulizer equipment could potentially lead to decreased oxygenation and infection for the resident.
Failure to Coordinate Dialysis Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of dialysis care for a resident who required such services. The resident, who had a history of stroke, kidney stones, respiratory failure, COPD, diabetes, chronic kidney disease, renal dialysis dependence, morbid obesity, and heart failure, was admitted to the facility with multiple hospital discharges and readmissions. The resident attended dialysis offsite three times a week and was supposed to bring back a packet of papers from dialysis. However, the facility's Hemodialysis Communication Forms often lacked critical information, such as the dialysis access site location and post-dialysis dressing change instructions. Additionally, the forms did not specify the type of dialysis access site or its location, which is essential for proper assessment. The facility's records, including physician orders and the Medication Administration Record, did not mention the resident's dialysis access site. Although the Treatment Administration Record required documentation of the dialysis site assessment within one hour of the resident's return from dialysis, the nurses only documented vital signs without assessing the dialysis site. The Care Plans indicated the need for a post-dialysis assessment, including documentation of the fistula site and signs of bleeding, but this was not consistently done. The Director of Nursing acknowledged the lack of documentation and assessment, noting that the dialysis center nurses were not completing their portion of the assessment on the communication form.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 26.19% error rate. This was due to the omission and untimely administration of medications for two residents. Resident #224 did not receive Protonix 40mg due to it not being available in the facility, and their Symbicort inhaler was not administered during the observed medication pass. Additionally, several medications for Resident #224 were administered late, including Augmentin ES-600 and Calcium Carbonate, which were given over two hours and one hour late, respectively. Resident #322 also experienced delays in medication administration. Medications such as Aspirin EC, Acetaminophen, Omeprazole, Prednisone, Folic Acid, and Lexapro were all administered late. The nurse responsible for administering these medications, Nurse L, acknowledged the delays and attributed them to starting late and not being able to administer the medications on time. The Clinical Supervisor (CS) was interviewed regarding the late medications and indicated that delays were often due to residents not wanting to wake up early or being on leave of absence. The CS also mentioned that the 400 hall was a heavy floor, making it challenging to administer medications within the two-hour window allowed by the facility's policy.
Improper Medication Storage and Handling
Penalty
Summary
The facility failed to properly store medications, including a narcotic medication, during a medication administration task. During an observation, a nurse was seen preparing medication for a resident and placing it in a cup, along with the resident's inhaler, in the top drawer of the medication cart. The nurse then retrieved additional medication from the medication storage room refrigerator. Upon returning, the nurse administered the medications to the resident but did not retrieve or administer the inhaler, which was left in the drawer. Another cup of medications, belonging to a different resident, was also found in the drawer, including Lyrica, a controlled substance. When questioned, the nurse was unaware of the facility's policy regarding the storage of medication in the medication cart and acknowledged that controlled substances should be stored under two locks. The Director of Nursing confirmed that medications should not be left in the cart for extended periods and that narcotics should be stored in a locked narcotic box. A review of the facility's policies indicated that inhalers should be stored in their original boxes and that narcotics must be kept in a locked box on the medication cart or in a medication room.
Inadequate Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship and monitoring program, resulting in inappropriate use of antibiotics for two residents. Resident #2, who had a history of traumatic brain injury, paraplegia, and chronic kidney disease, among other conditions, experienced frequent urinary tract infections (UTIs) and was administered multiple antibiotics without effective monitoring. The Infection Prevention and Control (IPC) Nurse A admitted that there was no consistent review of urinalysis or culture and sensitivity (C&S) reports, leading to the resident receiving a variety of antibiotics until a multi-drug resistant organism (MDRO) was identified. The lack of Infection Control Committee meetings and failure to review antibiotic appropriateness with providers contributed to the issue. Resident #21, who had diagnoses including diabetes and heart failure, was also subjected to inappropriate antibiotic use. Despite a urine culture showing no significant growth, the resident continued to receive Ciprofloxacin for the full duration initially prescribed. The IPC Nurse A acknowledged that the antibiotic should have been discontinued after the culture results, but it was not, due to a lack of documentation and oversight. The facility's policy on antimicrobial stewardship, which required antibiotic use and resistance data to be reviewed in IPC meetings, was not followed. The facility's policies on infection prevention and control, as well as antimicrobial stewardship, were not effectively implemented. The IPC Nurse did not routinely document infections or antibiotic use, and there were no Infection Control Committee meetings since February 2024. This lack of oversight and communication with providers led to inappropriate antibiotic use, as evidenced by the cases of Resident #2 and Resident #21. The facility's failure to adhere to its own policies resulted in deficiencies in antibiotic stewardship and monitoring.
Failure to Monitor Hydration and Notify Family
Penalty
Summary
The facility failed to properly assess and monitor the hydration status of a resident, leading to an undocumented administration of intravenous (IV) fluids and a lack of family notification. The resident, who had a medical history including Diabetes Type 2, Dysphagia, and Chronic Kidney Disease, was admitted with a high sodium level indicating dehydration. Despite the physician assistant's order to administer a 1-liter bolus of normal saline, there was no documentation on the amount of IV fluid received or the infusion rate. The resident eventually removed the IV, and there was no record of how much fluid was administered before this occurred. The Director of Nursing (DON) confirmed the absence of documentation regarding the IV fluid administration and acknowledged that the resident's family was not informed about the IV or its removal. The resident was later admitted to the hospital with a diagnosis of Hypernatremia and critical sodium levels. The lack of documentation and communication with the family contributed to the resident's hospitalization.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to implement policies and procedures to mitigate potential adverse consequences of psychotropic medications for a resident with dementia. The resident, a 57-year-old male with early onset Alzheimer's disease and other forms of dementia, was admitted to the facility without any psychotropic medications. However, during his stay, he was prescribed multiple psychotropic medications, including Ativan, Haldol, Klonopin, Lexapro, Lurasidone, Olanzapine, Risperdal, and Trazadone. The facility did not conduct baseline laboratory testing or ongoing monitoring to identify potential adverse effects of these medications, which are known to affect liver and kidney function. The resident's health rapidly declined, leading to decreased liver and kidney function, and he was transferred to the hospital multiple times before passing away. The facility's records showed no documentation of baseline or initial monitoring prior to the initiation of psychotropic medications. Interviews with the Assistant Director of Nursing (ADON) confirmed that baseline laboratory tests and EKGs were not completed, and the facility did not typically perform these tests for residents admitted from home. The ADON acknowledged that the facility's policy required consent and education about the risks and benefits of psychotropic medications, but this was not adequately communicated to the resident's family. The family member of the resident expressed concerns about the facility's ability to care for a younger individual with dementia and the lack of awareness about the side effects of the medications. The family member noted that the resident was ambulatory upon admission but became wheelchair-bound and hunched over due to the medications. The facility's failure to conduct necessary baseline testing and provide adequate education and consent contributed to the resident's decline in health and eventual death.
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 20 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 Sandusky
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumnwood Of Deckerville | 8.5 mi | ★★★★★ | 8 | 0 |
| Marlette Community Hospital Ltcu | 14.1 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Yale | 20.3 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Cass City | 21.8 mi | ★★★★★ | 12 | 0 |
| Courtney Manor | 27.4 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.