Eaton County Medical Care Facility

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 118 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview and record review the facility failed to provide impactful and meaningful activities for four Residents (#24, #55, #104, & #109) of four residents reviewed for activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #8) of 24 reviewed for MDS assessments. Review of the clinical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 8 (R8) was admitted to the facility on [DATE] with acute respiratory failure. The MDS dated [DATE] revealed Section N0415 question 1. E. was coded Yes for having been administered an anticoagulant medication within the last 7 days. Review of R8's Medication Administration Record (MAR) for November 2025 and monthly Physician orders for November 2025 revealed, R8 was not prescribed or administered an anticoagulant medication. On 02/12/26 at 3:10pm, during an interview with Registered Nurse/MDS Coordinator C, R8's November MDS, MAR and physician orders were reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when five medication errors were observed from a total of 35 opportunities for four residents (R42, R58, R100, and R129) of seven reviewed resulting in a medication error rate of 14.29%.

Inspectors wroteBased on observation and interview, the facility failed to dispose of expired medications in two of four medication carts, appropriately store refrigerated medications in one of three medication storage rooms reviewed, and secure medications (R97), resulting in the potential for decreased efficacy of medications, medication contamination, medication errors and adverse side effects in a current facility census of 127 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 1 residents (#329) of 2 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers potentially affecting up to the facility census of 127 residents.

Inspectors wroteBased on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act 42CFR483.12(c)

Inspectors wroteBased on interview and record review, the facility failed to ensure all injuries of unknown source were thoroughly investigated, in one of one resident (R#22) reviewed for abuse, resulting in the potential for injuries of unknown origin not being investigated.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#20) of 21 residents reviewed for accurate assessments. Findings Included: Resident #20 (R20) Review of the medical record revealed R20 was admitted to the facility 07/13/2018 with diagnoses that included heart failure, chronic kidney disease, end stage renal disease, dependence on renal dialysis, atrial fibrillation, type 2 diabetes, peripheral vascular disease (PVD), hypothyroidism (low thyroid hormone), atherosclerosis (plaque in arteries), hypotension, pneumonia, insomnia, depression, anemia (low red blood cells), and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date of 09/18/2024, revealed R20 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete adequate monitoring for the use of an anticoagulant (blood thinner) medication for one (R100) of five reviewed.

Inspectors wroteThis citation includes intake MI00144331. Based on observation, interview and record review, the facility failed to act promptly on grievances and or concern forms reported in and out of resident council meetings and provide responses and resolutions to 26 grievances filed in the last six months, as reported during a confidential resident council meeting, resulting in unresolved resident concerns and decreased quality of life.

Inspectors wroteBased on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R37) of three reviewed for pressure ulcers, resulting in facility acquired stage 3, a deep tissue pressure injury, and unstageable pressure wounds and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) maintain sanitary food and non-food contact surfaces, 2) store chemicals away from food, 3) maintain equipment, and 4) provide ventilation for steam exhausting equipment, resulting in the potential for foodborne illness, chemical contamination, and improper ventilation. These deficient practices affect all 112 residents who consume food from the kitchen.

Inspectors wroteThis citation pertains to intakes MI00139713 and MI00139715. Based on interview and record review, the facility failed to permit a resident to return to the nursing home following a hospitalization stay, in 1 of 3 residents reviewed for hospitalization (R317), resulting in loss of home, limited access to social support and decreased quality of life. R317's Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/08/23 revealed he was admitted on [DATE]. R317 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 07 (00-07 Severe Impairment). The same MDS revealed R317 had physical behavioral symptoms directed toward others that occurred 1 to 3 days during the 7-day look-back period. R317 had verbal behavioral symptoms directed toward others that occurred 1 to 3 days during the 7-day look-back period. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate medication storage for one of three medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Personal Protective Equipment (PPE) was worn per standards of practice for one residents (Resident #85) of 8 residents reviewed during medication pass, resulting in the potential for the transmission/transfer of pathogenic organisms and cross contamination for vulnerable residents. Findings Include: During an observation on 10/31/23 at 8:10 a.m., Registered Nurse (RN) L entered R85 room after preparing several medication to be administered through R85's PEG tube. This surveyor observed a sign posted outside R85 room for Enhanced Barrier Precautions that included use of gown and gloves. RN L administered R85 medications via the Peg tube with use of gloves only. [...]