Above 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 Wexford Senior Care Center during CMS and state inspections, most recent first.
A resident's advance directive and code status form both indicated a desire for life-support and CPR, but after the resident was deemed unable to make healthcare decisions, the POA signed a DNR order that contradicted these wishes. The DON acknowledged the conflict and lack of documentation regarding the resident's previously expressed preferences, resulting in the resident's end-of-life care decisions not being honored.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
The facility failed to maintain proper food storage and temperature control, risking foodborne illness for 62 residents. Observations revealed ground meat in the steam table below the required 135 F, and cooling logs for goulash and scallop potatoes lacked proper documentation. The Registered Dietitian could not explain the temperature discrepancies.
The facility failed to implement enhanced barrier precautions (EBP) for several residents, as required by their policy. Observations revealed a lack of EBP signage and PPE availability for residents with conditions like wounds or indwelling devices. Staff, including a nurse and a CNA, did not use proper PPE during care activities. The Infection Preventionist and DON misunderstood EBP application, believing it was only for known infections, contrary to policy requirements.
Two residents in a facility were found without catheter securement devices, leading to potential risks of catheter dislodgement. One resident with moderately impaired cognition was observed without a securement device during a wound dressing change, while another resident with intact cognition reported a pulling sensation from the catheter tubing. The facility's policy requires catheters to be secured every shift, which was not followed.
A resident with a PEG tube was not provided with properly administered and documented tube feeding. Observations revealed undated feeding bottles and flush bags without nursing initials over several days. The MAR lacked accurate documentation of the tube feed amount, contrary to the resident's nutritional assessment. The RD's recommendations for continuous feeding were not correctly reflected in the physician's order, leading to inadequate monitoring of nutritional intake.
Failure to Honor Resident's Advance Directive for Code Status
Penalty
Summary
The facility failed to honor a resident's advance directive regarding code status. The resident had a Power of Attorney (POA) document specifying that she wanted life-support treatment to the greatest extent possible for at least 30 days, after which her preference would change to not wanting life-support if certain conditions existed. This document was signed by the resident while she was competent. Additionally, a code status form signed by the resident indicated her wish to receive CPR in the event of cardiopulmonary arrest. Later, when the resident was determined to be unable to make healthcare decisions, the POA was activated, and the resident's daughter, acting as POA, signed a DNR (Do Not Resuscitate) order for the resident, which contradicted the resident's previously expressed wishes in her advance directive and code status form. The Director of Nursing (DON) acknowledged the conflicting information between the resident's advance directive and the DNR order signed by the POA. There was no documentation of any discussion with the POA regarding the resident's express wishes prior to the change in code status. When interviewed, the resident appeared confused but verbally expressed a desire for CPR. The facility's policy required honoring residents' wishes as expressed in valid advance directives, but this was not followed in this case, resulting in the resident's end-of-life care decisions not being honored.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Deficient Food Storage and Temperature Control
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among the 62 residents. During an observation, the steam table in the kitchen was found to have food ready for the noon meal, but the temperature of the ground meat was measured at 112 F, 114 F, and 116 F, which is below the required 135 F. Despite the initial claim by a staff member that the temperature was 147 F, a subsequent measurement confirmed the lower temperatures. The Registered Dietitian (RD) was unable to explain the significant temperature drop of over 20 degrees within a short period. Additionally, during a morning observation of the walk-in cooler, a stainless steel pan labeled as goulash and another pan of scallop potatoes from the previous day were found on a cart. The cooling logs showed an initial temperature of 135 F at 1:20 PM, but there was no further documentation of the cooling process. The RD stated that these products would be disposed of. According to the FDA Food Code 2017, cooked time/temperature control for safety food must be cooled from 135 F to 70 F within two hours and then to 41 F or less within a total of six hours, which was not documented in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for six residents who were identified as meeting the criteria for EBP. During observations, it was noted that there were no EBP signs on the doors of these residents to alert staff to use personal protective equipment (PPE). Additionally, there were no carts available in these areas to store necessary PPE such as gloves, gowns, and shields. This oversight was observed in multiple rooms where residents had conditions like wounds or indwelling medical devices, which require EBP to prevent the transmission of multi-drug resistant organism (MDRO) infections. Specific instances of non-compliance were observed, including a registered nurse failing to don PPE during wound care for a resident, an LPN not wearing a gown during a medication pass via a peg tube, and a CNA not using proper PPE during urinary catheter care. The Infection Preventionist and the Director of Nursing both misunderstood the application of EBP, believing it was only necessary for residents with known or suspected infections, rather than also for those with certain conditions or devices. The facility's policy on EBP, which requires clear signage and the availability of PPE, was not followed, leading to these deficiencies.
Failure to Ensure Catheter Securement Devices in Place
Penalty
Summary
The facility failed to ensure that catheter securement devices were in place for two residents, leading to potential risks of catheter dislodgement. Resident #20, who had moderately impaired cognition and required extensive assistance, was observed without a catheter securement device during a sacral wound dressing change. The Registered Nurse acknowledged the absence of the securement device and confirmed that it should have been in place to prevent the catheter tubing from being pulled during care or movement. Similarly, Resident #64, who had intact cognition and required extensive assistance, was observed with a taut catheter tubing and reported feeling a pulling sensation. The resident confirmed that a securement device was previously used but was no longer in place. The Director of Nursing confirmed that all residents with indwelling catheters should have securement devices, yet Resident #64's care plan lacked an order for such a device. The facility's policy mandates that catheters be secured to the leg every shift, which was not adhered to in these cases.
Failure to Properly Administer and Document Tube Feeding
Penalty
Summary
The facility failed to ensure proper administration and documentation of tube feeding for a resident with a PEG tube. The resident, who was admitted with diagnoses including dysphagia, esophageal perforation, and moderate protein-calorie malnutrition, was observed on multiple occasions with undated tube feeding bottles and flush bags lacking nursing initials. This lack of proper labeling and documentation was noted over several days, indicating a failure to adhere to standards of practice for tube feeding administration. Additionally, the resident's Medication Administration Record (MAR) did not accurately document the amount of tube feed received over a 24-hour period, as required by the resident's nutritional assessment. The Registered Dietitian had recommended continuous tube feeding, but the physician's order in the MAR was not documented correctly, leading to inadequate monitoring of the resident's nutritional intake. The Charge Nurse confirmed these documentation issues, acknowledging that the physician order was incorrect and that staff failed to label and initial the tube feeding supplies properly.
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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 Cadillac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumnwood Of Mcbain | 10.2 mi | ★★★★★ | 0 | 0 |
| Corewell Health Reed City Hospital Rehabilitation | 25.5 mi | ★★★★★ | 9 | 0 |
| Grand Oaks Nursing Center | 32 mi | ★★★★★ | 2 | 0 |
| King Nursing & Rehabilitation Community | 32.6 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Traverse City | 35 mi | ★★★★★ | 0 | 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.