Below 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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Schoolcraft Medical Care Facility during CMS and state inspections, most recent first.
A resident with severe cognitive and visual impairment, known elopement risk, and repeated exit-seeking behaviors was able to leave the facility undetected and was found over a mile away after being missing for two hours. Despite prior incidents and a high elopement risk score, staff did not update the care plan or implement interventions, and the resident was moved out of the secure memory care unit without documented justification.
The facility failed to implement an effective infection control program during a Norovirus outbreak, affecting 18 residents. Disinfection practices were inadequate, with improper use of bleach solutions and lack of outbreak surveillance. Communal dining continued, and staff were not properly educated on hand hygiene, as observed with an RN failing to use gloves or perform hand hygiene during resident care. The facility's policies were not followed, contributing to the sustained outbreak.
The facility inaccurately reported PBJ information to CMS, resulting in deficiencies such as no RN hours and lack of 24-hour licensed nursing coverage. The issue arose from a failed switch in data conversion companies, as acknowledged by the Human Resource Manager and Nursing Home Administrator.
The facility failed to report and investigate potential abuse incidents involving residents with severe cognitive impairment. One resident was found in bed with another and became combative, resulting in a hand injury, while another incident involved the same resident unclothed with another resident. These incidents were not reported as allegations of abuse to the NHA or SA, despite facility policy requiring such actions.
The facility failed to investigate allegations of abuse involving residents with severe cognitive impairment. A resident was found inappropriately in bed with others on multiple occasions, and another resident was found lying on top of another. Despite these incidents, no investigations or incident reports were initiated, and the facility did not adhere to its policy on abuse prevention and prohibition.
Failure to Implement Elopement Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement, severe cognitive impairment due to Alzheimer's disease, and significant visual impairment was able to leave the facility undetected. The resident had previously demonstrated exit-seeking behaviors, including playing with door codes, expressing a desire to leave, and having a documented high elopement risk score. Despite these clear risk factors, the facility failed to implement appropriate interventions or update the resident's care plan to address elopement risk, even after prior incidents where the resident exited the facility and was returned. The facility's own policies required that residents identified as at risk for elopement have these issues addressed in their individual care plans. However, after multiple incidents where the resident left or attempted to leave the facility, there was no investigation, incident report, or care plan developed to mitigate the risk. The resident was also moved out of the memory care unit without documented justification, despite meeting the criteria for continued placement in that secure environment. Staff interviews confirmed that no care planning or interventions were put in place after previous elopement attempts, and the resident's risk was not reassessed or addressed in the care plan. On the day of the incident, the resident exited the facility by following a visitor through a door, walked outside the premises, and was later found at a fast-food restaurant over a mile away after being missing for approximately two hours. The resident's family and staff had previously expressed concerns about his desire to leave and his increased agitation following his wife's death. The lack of timely and appropriate interventions, failure to follow facility policy, and absence of a care plan addressing elopement risk directly led to the resident's undetected exit and the resulting immediate jeopardy situation.
Removal Plan
- R #1 is residing in the Memory Care Neighborhood, a secured unit.
- R #1 Elopement Assessment has been updated, and a care plan has been developed with appropriate interventions.
- All residents have an Elopement Assessment and were audited to ensure that if they have a score higher than 10, they have a care plan in place with appropriate interventions.
- All staff have reviewed and signed a copy of the Facility Elopement Policy.
- The Director of Nursing, or designee, will audit all new admissions for elopement risk and ensure appropriate interventions are in place.
- The Director of Nursing, or designee, will audit residents, based on MDS schedule, to ensure Elopement Assessment is completed and appropriate interventions are in place.
- The Director of Nursing was educated to review Elopement Assessments to ensure that proper care plan interventions are in place, based on the MDS schedule and admissions.
- The Northeast door code has been changed and only staff are allowed to have this code.
- All visitors and staff must enter and exit the facility through the front lobby only.
- All DPOA's and Emergency contacts will be contacted to let them know of the change.
- Signage will be posted.
- Staff education has been sent regarding these changes and to ensure they do not give out the code to the Northeast door and that they all use the front lobby to enter and exit.
- If staff hear the alarm go off, they need to remind the visitor to use the front lobby door, or if they cannot identify who set the alarm off, they need to call a code missing person and start a headcount.
- All physician orders and physician progress notes have been reviewed for R #1 and have been placed.
- Resident is utilizing nonpharmacological interventions, residing in the memory care unit, and on antidepressant medications, per Behavioral Care Solutions recommendations.
Inadequate Infection Control During Norovirus Outbreak
Penalty
Summary
The facility failed to implement a comprehensive infection control program during a Norovirus outbreak, affecting 18 residents out of a total census of 63. The outbreak began with three residents developing symptoms of emesis and diarrhea, with two residents hospitalized. The facility did not perform effective disinfection, as observed when a housekeeper used a bleach solution that was not properly saturated and did not adhere to the required contact time for disinfection. The facility's housekeeping policies lacked specific instructions on how to appropriately disinfect surfaces during an outbreak. The facility also failed to conduct proper outbreak surveillance and did not provide adequate education or monitoring to mitigate the spread of Norovirus. The Infection Preventionist provided a summary of events but lacked detailed information on education or auditing efforts. Communal dining and activities continued despite the outbreak, and there was no posting of the outbreak at the facility entrance. The Director of Nursing and other staff members were unaware of the proper procedures for handling the outbreak, including the use of hand hygiene and isolation precautions. Additionally, there were significant lapses in hand hygiene practices. An RN was observed administering medications and performing wound care without using gloves or performing hand hygiene. This included applying barrier cream to an open wound and handling a tissue box that had fallen on the floor without subsequent hand hygiene. The facility's hand hygiene policy was not followed, and the NHA acknowledged the failure in infection control practices, especially during the ongoing Norovirus outbreak.
Inaccurate PBJ Reporting Leads to Staffing Deficiencies
Penalty
Summary
The facility failed to report accurate Payroll Based Journal (PBJ) information to the Centers for Medicare and Medicaid Services (CMS), resulting in inaccurate staffing level reports. The CMS PBJ Staffing Data Report for Fiscal Year Quarter 4 2024 indicated several deficiencies, including no Registered Nurse (RN) hours and a lack of licensed nursing coverage 24 hours a day from July 1 to September 30, 2024. During interviews, the Human Resource Manager revealed that a switch in companies responsible for data conversion and submission to CMS did not function correctly, leading to the reporting errors. The Nursing Home Administrator acknowledged that the report was not created correctly. The facility's policy for PBJ reporting was requested but not provided before the survey exit.
Failure to Report and Investigate Potential Abuse Incidents
Penalty
Summary
The facility failed to develop and implement policies and procedures for identifying and reporting potential abuse for several residents, leading to the potential for unidentified abuse and further exposure to abusive situations. Resident #10, who had severe cognitive impairment and was independent with transfers and ambulation, was involved in multiple incidents that were not properly reported or investigated. On one occasion, Resident #10 was found in bed with another resident and became combative when redirected, resulting in a hand injury. Despite the incident being documented, it was not reported as an allegation of abuse to the Nursing Home Administrator (NHA) or the State Agency (SA). Another incident involving Resident #10 occurred when they were found unclothed in bed with another resident. This incident was documented in the electronic medical record but was not followed by an incident report or investigation. The Director of Nursing (DON) was only made aware of the incident through behavior notes and did not report it as an allegation of abuse. Similarly, Resident #14 was involved in an incident where they were found lying on top of another resident, but no incident report or investigation was initiated, and the NHA was not informed. The facility's policy on abuse prevention and prohibition requires immediate reporting of abuse or neglect to the facility Administrator and/or the DON, and further reporting to the mandated state agency. However, the facility staff failed to adhere to these policies, resulting in a lack of proper identification and reporting of potential abuse incidents. The NHA acknowledged the failure to report these incidents and recognized them as allegations of abuse that should have been reported to the SA.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving five residents. Resident #10, who had severe cognitive impairment, was involved in multiple incidents where he was found inappropriately in bed with other residents. On one occasion, he was found in a female resident's bed and became combative when redirected, resulting in an injury to his hand. However, there was no documentation on how the injury occurred. Another incident involved Resident #10 being found unclothed in bed with another male resident, but no incident report was filed, and no physical or psychosocial assessments were conducted. Resident #14, also with severe cognitive impairment, was found lying on top of another resident in their bed. The incident was reported to a nurse, but no investigation or incident report was initiated. The Director of Nursing (DON) was aware of some incidents but did not conduct investigations, citing the residents' inability to recall the events. The Nursing Home Administrator (NHA) confirmed that these incidents should have been investigated as allegations of abuse. The facility's policy on abuse prevention and prohibition requires immediate reporting and thorough investigation of alleged violations. However, the facility did not adhere to this policy, as evidenced by the lack of incident reports and investigations for the incidents involving Residents #10 and #14. The NHA acknowledged that a diagnosis of dementia does not negate the responsibility to investigate allegations of abuse, highlighting a failure to follow established procedures.
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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 Manistique
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Munising | 37.3 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.