Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Laurels Of Mt. Pleasant during CMS and state inspections, most recent first.
The facility failed to follow physician orders for catheter management for two residents. One resident with a suprapubic catheter had orders for routine changes every 30 days, but the catheter was not changed for more than two months before discharge, and staff could not explain why the order had been altered. Another resident with a urinary catheter related to obstructive uropathy wanted the catheter removed, and the record showed the facility did not follow up on a urology consult order for a prostate MRI.
The facility failed to maintain an accurate EMR for two residents. For one resident with cellulitis, sepsis, CKD, and adult failure to thrive, staff documented a decline in condition but did not record family notification or guardianship-related actions in the EMR. For another resident with TBI and bladder dysfunction, the care plan called for pain assessment and evaluation of morphine effectiveness, but the MAR and EMR lacked documentation of pain scores and response to medication.
Three dependent residents did not receive necessary assistance with activities of daily living, including help with eating, access to call lights, and scheduled showers. One resident was left unable to eat her meal or call for help, another was not offered lunch and experienced significant weight loss, and a third did not consistently receive showers on her preferred days, with documentation supporting missed care.
A resident with anxiety and major depressive disorder, who was cognitively intact, was started on Pristiq without being informed of the risks and benefits prior to initiation. Facility staff and record review confirmed that required education and documentation were not provided, despite facility policy mandating such communication for psychotropic medications.
A resident with multiple complex medical conditions experienced significant, unaddressed weight loss after the facility failed to follow its own policies for regular weight monitoring and interdisciplinary communication. The resident's care plan called for at least monthly weights and reporting of significant changes, but weekly monitoring was discontinued despite ongoing weight loss, and a required dietary evaluation was overdue. The absence of a dietary manager and limited dietitian availability contributed to the failure to identify and address the resident's nutritional decline.
The facility failed to ensure call lights were within reach for three residents, leading to potential unmet care needs. A resident with memory deficit and dementia had her call light clipped under her pillow, making it inaccessible. Another resident with mild cognitive impairment had her call light coiled up against the wall, out of reach. A third resident with cerebral infarction found her call light out of reach on two occasions, forcing her to yell for assistance. Despite their conditions, all residents were capable of using their call lights when accessible.
The facility failed to ensure proper use of Enhanced Barrier Precautions (EBP) and PPE for two residents, leading to potential cross-contamination. A resident with a tracheostomy and urinary catheter did not have appropriate signage for PPE due to embarrassment, and staff respected this request despite the need for EBP. Another resident with dementia experienced improper PPE use when a CNA used a dropped gown for care. These actions violated facility policies and increased infection risk.
A facility failed to complete a required Level II Screening for a resident with mental health diagnoses, including dementia and bipolar disorder. The screening had not been conducted since the resident's admission, as confirmed by the DON and Social Services Supervisor.
Failure to Follow Catheter Orders and Urology Follow-Up
Penalty
Summary
The facility failed to manage catheters according to physician orders for two residents. One resident had a suprapubic catheter and a care plan directing staff to change it every 30 days, and a hospice care plan also directed replacement of the catheter and drainage system every 30 days and when there was disconnection, leakage, or signs or symptoms of infection. Review of the record and interviews with the resident’s family, an RN, and the DON showed the suprapubic catheter had not been changed for more than two months before discharge, with the last documented change on 9/12/2025. The DON also reported nursing staff changed the order on 7/22/2025 but could not find supporting documentation explaining why the change occurred, and the urology note from 4/19/2024 had directed catheter changes every 4 weeks. A second resident had a urinary catheter related to obstructive uropathy. During interview, the resident stated he wanted the catheter removed and was unsure why it was still in place. Review of the urology consultation report showed the urologist ordered an MRI of the prostate, but there was no evidence the facility physician reviewed the consultation report. An RN Unit Manager later reported the facility failed to follow up with the urology order for the MRI of the prostate from June 2025.
Inaccurate EMR Documentation for Resident Notifications and Pain Monitoring
Penalty
Summary
The facility failed to maintain an accurate EMR for 2 residents reviewed for medical record accuracy. For one resident, who was admitted with cellulitis of the back, sepsis, chronic kidney disease, and adult failure to thrive, a progress note documented significant weight loss, declining health, refusal of meals at times, and staying in bed most of the time, with the NP and dietician aware. During interviews, the Unit Manager stated she had notified the resident’s family member about the change in condition but did not document that notification in the EMR. The Family Member reported the facility notified him sporadically and that the resident required a new guardian, and the Social Services Director stated he had begun the guardianship process and communicated with outside resources without documenting those actions in the EMR. For the second resident, who was admitted with traumatic brain injury and neuromuscular dysfunction of the bladder, the current pain care plan directed staff to administer pain medication, observe for effectiveness, and evaluate pain characteristics using a scale. Review of the November 2025 MAR showed the resident received morphine every 2 hours for pain, but there was no documentation of pain assessment or response to the medication, and no further EMR documentation showing staff used a pain scale to monitor pain or effectiveness. The DON stated staff should have been using a pain scale to document pain and verify the effectiveness of the medication, and that the order was not placed correctly for this to occur.
Failure to Provide ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three dependent residents. One resident, admitted with generalized weakness and complex medical conditions, was found lying on her side with an untouched lunch tray out of reach. She reported waiting approximately thirty minutes for staff to return and assist her to a position where she could eat, as she was unable to do so independently. The call light and bed control were not accessible, and the resident was also found to be wet with urine. Staff confirmed the call light and bed control were not within reach, contrary to facility policy requiring these items to be accessible to residents in bed. Another resident, re-admitted with hemiplegia, aphasia, and dysphagia, was observed without a meal tray while her roommate was eating. Staff interviews revealed that this resident typically required substantial assistance with eating and had recently experienced significant weight loss. The resident was not initially offered lunch, and when a tray was eventually provided, the food was unappealing and refused by the resident. The care plan indicated the resident was dependent on staff for eating, but observations and interviews showed that assistance was not consistently provided. A third resident, with heart failure and end-stage renal disease, reported not consistently receiving scheduled showers. Documentation and interviews confirmed that showers were not always offered or documented as refused on the resident's preferred non-dialysis days, despite her requests. Review of shower records showed multiple missed or undocumented shower opportunities over several months, supporting the resident's claim that care was not provided as scheduled. These findings collectively demonstrate a failure to provide necessary ADL care and assistance to residents who were dependent on staff.
Failure to Inform Resident of Risks and Benefits Before Initiating Psychotropic Medication
Penalty
Summary
A cognitively intact resident with diagnoses of anxiety disorder and major depressive disorder was admitted to the facility and subsequently started on Pristiq, a psychotropic medication, following a recommendation from a mental health nurse practitioner. Review of the resident's records, including the Minimum Data Set and physician's orders, confirmed the initiation of Pristiq. However, there was no documentation in the electronic medical record that the risks and benefits of Pristiq were reviewed with the resident prior to starting the medication. Interviews with facility staff, including the Social Services Assistant and the Director of Nursing, confirmed that there was no evidence of risk versus benefit education provided to the resident for the antidepressant medication. The facility's policy required that residents, families, or representatives be informed of the benefits, risks, and alternatives before initiating any psychotropic medication. The resident also reported not knowing she was taking Pristiq and did not recall receiving any education about the medication prior to its initiation.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess, monitor, and identify significant weight loss for one resident with multiple complex medical diagnoses, including partial traumatic amputation, acute osteomyelitis, vascular dementia, depression, anxiety disorder, and type 2 diabetes with a foot ulcer. The resident was identified as being at nutritional risk, with care plan interventions requiring at least monthly weights and reporting of significant weight changes to the physician and dietitian. Despite a dietitian's recommendation for ongoing weekly weights, the resident experienced an 8.54% weight loss over less than a month, and weekly weight monitoring was discontinued. The resident's weight continued to decline, reaching a total loss of 10.39% over a short period. The facility's policy required regular monitoring and interdisciplinary communication regarding significant weight changes, but these processes were not followed. The facility had been without a dietary manager for several months, relying on a contract dietitian working offsite only one day per week. Additionally, the required Diet History/Food Preferences Evaluation for the resident was 45 days overdue. These lapses resulted in a failure to promptly identify and address the resident's significant weight loss as required by facility policy and the resident's care plan.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to potential unmet care needs. Resident #5, who has memory deficit and dementia, was observed on multiple occasions with her call light clipped to her bed sheet under her pillow, making it invisible and inaccessible to her. Despite being able to use the call light, Resident #5 was unable to locate it when asked. Similarly, Resident #8, with mild cognitive impairment and dementia, had her call light coiled up on a small organizer against the wall, out of her reach. She was unable to find the call light when questioned, as it was obstructed by her bedside table. Resident #68, diagnosed with cerebral infarction and depression, was found with her call light out of reach on two separate occasions. Initially, it was placed in the middle of her bed, and later, it was found below her feet. Resident #68 reported that staff often left her call light out of reach, forcing her to yell for assistance. Despite having contractures, she was able to activate the call light when it was placed near her hand. CNA G confirmed that Resident #68, along with Residents #5 and #8, were capable of using their call lights to request assistance when they were within reach.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to ensure proper use of Enhanced Barrier Precautions (EBP) and Personal Protective Equipment (PPE) for two residents, leading to potential cross-contamination and infection spread. Resident #12, who had a tracheostomy and urinary catheter, did not have appropriate signage for PPE requirements due to the resident's embarrassment. Despite the need for EBP, there was no physician's order for such precautions, and staff respected the resident's request to remove the signage, citing resident rights and dignity. Additionally, a CNA entered Resident #12's room without donning PPE and failed to sanitize the vitals cart before and after use. Resident #5, diagnosed with memory deficit and dementia, was observed to have improper PPE use. A CNA dropped a disposable gown on the floor, picked it up, and proceeded to use it for patient care, contrary to infection control protocols. The Director of Nursing confirmed that dropped PPE should be disposed of and not used. The facility's policies on Enhanced Barrier Precautions and infection prevention were not followed, as evidenced by the lack of proper signage and PPE use, as well as the failure to sanitize shared medical equipment. These lapses in protocol increased the risk of cross-contamination and infection spread within the facility.
Failure to Complete Required Level II Screening for Resident
Penalty
Summary
The facility failed to complete a Mental Illness/Intellectual Disability/Related Condition Exemption Criteria Certification Level II Screening (DCH-3878) for a resident, resulting in the potential for unmet mental health needs. The resident was admitted to the facility with diagnoses including dementia, bipolar disorder, depression, and anxiety. A review of the resident's Annual Resident Review (ARR) form, dated February 20, 2024, indicated that the resident had conditions that required a Level II Screening. However, there was no documentation that this screening was completed. Interviews with facility staff revealed that the Level II Screening had not been conducted since the resident's admission in October 2020. The Social Services Supervisor acknowledged the oversight and was unsure why the screening was missed. The Director of Nursing confirmed the need for the screening and noted that the Social Services Director was working on addressing the issue.
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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 Mt. Pleasant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Isabella County Medical Care Facility | 0.2 mi | ★★★★★ | 8 | 0 |
| Medilodge Of Mt. Pleasant | 1.5 mi | ★★★★★ | 6 | 0 |
| Riverside Healthcare Center | 14.8 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Clare | 15 mi | ★★★★★ | 5 | 0 |
| Michigan Masonic Home | 15.3 mi | ★★★★★ | 17 | 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.