Ingham County Medical Care Facility

Inspectors wroteCitation pertains to intake #3039609Based on interview and record review, the facility failed to protect and keep one resident (R70) of one resident safe from accidents that include elopement. Findings Include;Resident #70 (R70)Review of the medical records reflected that R70 was admitted to the facility on [DATE]. Diagnoses of Dementia, Anxiety and Depression. R70 was hospitalized and not on site at the facility during the survey. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2026 revealed R70 had a Brief Interview of Mental Status (BIMS) of 05 (Severe cognitive impact) out of 15. R70 wore a wander guard (security system used to protect residents who are prone to wandering). Record review revealed R70 verbalized an exit plan upon admission to the facility and a wander guard was placed on her right ankle. [...]

Inspectors wroteThis citation pertains to Intake 3029138. Based on observation, interview, and record review, the facility failed to report a resident-to-resident sexual abuse allegation to the State Agency for two (R1 and R2) of three reviewed.

Inspectors wroteThis citation pertains to intake number 3029138. Based on interview and record review the facility failed to ensure a comprehensive care plan was in place for one out of three residents (Resident #2). Findings Inlcuded:Per the facility face sheet Resident #2 (R2) was admitted to the facility on [DATE]. Review of a Brief Assessment for Mental Status (BIMS) dated 4/16/2026 revealed R2 had a BIMS score of 15 out of 15 which indicated full cognitive abilities. Review of a progress note dated 4/28/2026 revealed R2 became upset the night before when she was asked to leave another resident's (R1) room. Review of a social service progress note dated 5/19/2026 revealed R2 was met with in order to discuss R2 interfering with R1's care, to not wake R1 while sleeping, and to leave and return later if R1 was in the bathroom or receiving care. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) provide palatable food products, and (2) provide consistent dietary glassware and flatware affecting 131 residents who consume food, resulting in the increased likelihood for resident decreased food acceptance, nutritional decline, and undignified dining.

Inspectors wroteBased on observations, interviews, and record reviews, the facility to effectively clean and maintain food service equipment affecting 131 residents who consume food, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents were treated with dignity and respect when residents were required to use plastic silverware for meals which diminished the homelike dining experience in two (Resident #33 and #73) and the potential to affect all residents that utilize utensils during meal service.

Inspectors wroteBased on interview and record review the facility failed to complete accurate Minimum Data Set (MDS) assessments for four resident (#7,#47,#72,#145) of 26 residents reviewed for MDS accuracy, resulting in inaccurate MDS assessments. Findings Include Resident #47 (R#47) Review of the medical record reflected that R47 was admitted to the facility on [DATE] and discharged on 12/10/2025. Diagnoses of displaced fracture of upper end of the left humerus, unspecified sequelae of cerebral infarction (a range of long-term effects and complications), Type 2 Diabetes Mellitus, heart failure and blindness in right eye. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/12/2025 revealed R47 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate monitoring of a resident prescribed an antipsychotic medication in one (Resident #93) out of 5 reviewed for medication review.

Inspectors wroteThis Citation Pertains to Intake #2649987 Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.

Inspectors wroteThis Citation Pertains To Intake #2649987 Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse for one resident (Resident #136) of seven residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive care plan for one resident R7 of 26 reviewed. Findings Included:Resident #7 (R7)Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bath/showers for one Residents (#13) of three Residents reviewed. Findings Included: Resident #13 (R13): Review of the medical record demonstrated that R13 was admitted to the facility 09/26/2023 with diagnoses that included cerebral infarction, schizoaffective disorder depressive, dementia, chronic obstructive pulmonary disease (COPD), atrial flutter, sleep disorder, hypertension, hyperlipidemia (high fat content in blood), and anxiety. Review of R13's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2025, revealed R13 had a Brief Interview for Mental Status (BIMS) of 09 (severe cognitive impairment) out of 15. During observation and interview on 12/09/2025 at 01:39 p.m. R13 was observed sitting up wheelchair. [...]

Inspectors wroteDuring interviews, observations and record review the facility failed to provide meaningful activities to one of one resident (R86) resulting in boredom, isolation and disengagement. Findings Include Resident #86 (R86)Review of the medical record reflected that R86 was admitted to the facility on [DATE]. Diagnoses of traumatic subdural hemorrhage without loss of consciousness, fracture of left great toe, emphysema, atrial fibrillation, heart failure, dyspnea with repeated falls. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/2025 revealed R86 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section GG0115, Functional Limitation in Range of Motion reveals R86 had impairment on both sides, used a walker and wheelchair for ambulation and required substantial/maximal assistance for all care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident safety during staff assisted mechanical lift transfer for 1 of 3 sampled residents (Resident #3) reviewed for accidents, resulting in Resident #3 right lower leg laceration that required hospital transfer and sutures. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic osteomyelitis, heart failure, morbidly obese, diabetes, venous insufficiency, and depression. The MDS reflected R3 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required staff assist with dressing, hygiene, bathing and transfers. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and document interventions designed to prevent further weight loss, including consistent monitoring and documentation of dietary intake, nutritional supplements, and snacks in two (Resident #10, Resident #116) out of 4 reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that bed rails were assessed and measured to prevent possible entrapment for one Resident (#7) of one resident reviewed for Residents using bed rails. Findings Included:Resident #7 (R7)Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure monitoring and inspection of resident bed frames and mattress for one resident (#7) of one resident reviewed for bed safety. Findings Included: Resident #7 (R7):Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. [...]

Inspectors wroteThis citation pertains to intake 2575199. Based on observation, interview and record review, the facility failed to protect R1's right to be free from sexual abuse by R2 and R4. Findings Include: R1:Review of the medical record reflected R1 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/19/25, reflected R1 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was independent for transfers and walking at least 150 feet. R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure witnesses observed the signing of a Do-Not-Resuscitate (DNR) document by one (Resident #78) of one reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to implement appropriate preventive measures and take corrective action for allegations of abuse for 3 of 3 residents (R#'s 9, 113 and 33) reviewed for abuse.

Inspectors wroteThis citation pertains to MI00146701 Based on observation, interview, and record review, the facility failed to meet transfer/discharge documentation requirements for 2 of 2 reviewed (R#19 & R#39) from a total of 24 sampled residents, resulting in the potential for these residents and/or their representatives not obtaining their due rights.

Inspectors wroteThis citation pertains to MI00146701 Based on interview and record review the facility failed to provide a written copy to two of two residents (R #19 and R#39) reviewed for bed hold notification in a language that was understandable, resulting in potential for lack of understanding and knowledge for and what the bed hold policy entailed.

Inspectors wroteThis citation pertains to intake MI00146701. Based on interview and record review, the facility failed to permit timely readmission from the hospital for one (Resident #19) of two reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II determination was completed for two residents (Resident #83 and Resident #104) of two reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care planned interventions to promote the healing of wounds for one (Resident #78) of 24 reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a meaningful, diverse and engaging activity program for one resident (#58) of two reviewed for activities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drug regimens were reviewed at least once a month by a licensed pharmacist and provider, in one of five residents reviewed for medication management and monitoring (Resident #3), resulting in the potential for increased adverse consequences related to medication therapy.

Inspectors wroteBased on observation and interview, the facility failed to dispose of expired medications in one of four medication carts and one of three medication storage rooms reviewed, resulting in the potential for decreased efficacy of medications and adverse side effects in a current facility census of 132 residents.

Inspectors wroteBased on interview and record review, the facility failed to administer an influenza immunization per consent for one (Resident #46) of five reviewed.

Inspectors wroteThis citation pertains to Intake MI00142898. Based on observation, interview, and record review, the facility failed date mark all potentially hazardous ready-to-eat food products in two resident refrigerators of three reviewed.

Inspectors wroteThis Citation Pertains To Intake #MI00145470 Based on interview and record review, the facility failed to 1. ensure one resident (resident #7) of three residents reviewed were free of significant medication errors. 2. notify the physician of missed doses of physician ordered medication, resulting in the potential for increased seizure risk.

Inspectors wroteThis citation pertains to MI00139667 Based on observation, interview, and record review, the facility failed to immediately report abuse allegations for 1 Resident (Resident #6) of 3 reviewed for abuse resulting in allegations of abuse that were not reported to the Nursing Home Administrator (NHA) and the State Agency timely and the potential for further allegations of abuse to go unreported and not thoroughly investigated.

Inspectors wroteThis citation pertains to intakes MI00140195 and MI00140198 Based on observation, interview, and record review, the facility failed to ensure the protection of residents from abuse for two (Resident #7 and #8) of 7 reviewed, resulting in the potential for further abuse to occur. Findings Include: Resident #7 (R7) Review of the medical record revealed that R7 was admitted to facility [DATE] with diagnoses including unspecified dementia, heart failure, and insomnia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected that R7 was sometimes understood and sometimes able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 3 (Severe Cognitive Impairment). Section G of the same MDS revealed that R7 required one-person extensive assist for bed mobility, transfers, and toilet use. [...]

Inspectors wroteBased on observation, interview and record review the facility failed provide Activities of Daily Living (ADL) assistance to 2 sampled resident (Resident #5 and Resident #14), resulting in assistance with ADL and/or bowel/bladder not provided, the potential for skin breakdown, resident's needs to go unmet, discomfort and frustration to a reasonable person. Findings Include: Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included major depressive disorder, unspecified benign prostatic hyperplasia with lower urinary tract symptoms, cognitive communication deficit and anoxic brain damage. The Minimum Data Set (MDS) dated [DATE] revealed R5 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS). [...]

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 (R21) of four reviewed for pressure ulcers, resulting in R21 facility acquired stage 4 pressure wound(Full thickness tissue loss with exposed bone, tendon or muscle) that developed infection requiring antibiotic treatment, pain, 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 ensure cleanliness of kitchen equipment, food storage temperatures were documented, and food products were dated, resulting in the potential for food borne illness to occur in a current facility census of 171 residents. Findings Included: In an observation on 8/28/2023 at 9:14 AM, during the initial kitchen tour, revealed the juice machine had thick sticky debris on the pour spouts of the apple and cranberry juice, and the front of the juice machine observed to have sticky thick debris on it. During observation of the walk in cooler an opened bag of shredded cheese, which was not tied close, was observed to not have any date on the package of when the cheese package was opened, nor did it have a use by date on the bag. [...]

Inspectors wroteDuring an observation on 8/29/2023 at 8:20 AM, the call light for room [ROOM NUMBER], that was visible outside of the room door, was on. At 8:25 AM, five staff members were observed to walk past room and did not stop to address the resident's need. On 8/29/2023 at 8:44 AM, the call light was on for room [ROOM NUMBER] two staff members walked past and did not address the call light or resident needs, and at 8:48 AM, two other staff members walked by and did not address the call light or the resident's needs. At 8:49 AM, four other staff members were observed to walk by room [ROOM NUMBER] and did not stop and address the call light or the resident's needs. In an observation on 8/30/2023 at 9:44 AM, room [ROOM NUMBER]'s call light was on. Two staff members walked by room [ROOM NUMBER] and did not address the call light or the resident's needs. [...]

Inspectors wroteBased on interview, and record review the facility failed to assess, update, and ensure advance directive information was in place for 1 resident (Resident 109) of two residents reviewed, resulting in the potential for resident's preferences for medical care to not be followed by the facility staff. Findings Include: Resident #109 (R109) A review of the medical record revealed R109 admitted to the facility on [DATE] with diagnoses that included urinary tract infection, type 2 diabetes, aphasia, and adult failure to thrive. R109 had a brief interview for mental status (BIMS), a short performance based cognitive screen for nursing home residents, score of 10 (8-12 moderately impaired) which was completed on 8/26/2023. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident was free from physical restraints in one of one resident reviewed for physical restraints (Resident #59), resulting in the likelihood of injuries, depression, and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 3 (Resident #21, #34, and #309) of 32 residents reviewed resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise Care Plans for one (Resident #130) of 32 reviewed for Care Plans, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received assistance with care according to their personal preferences and care plans for 1 residents(R21) of 3 residents reviewed for hygiene and grooming , resulting in missed grooming, skin breakdown and the increased likelihood for inadequate hygiene and feelings of embarrassment.

Inspectors wroteDuring observation, interview, and record review the facility failed to provide failed to provide meaningful, individualized activities for one resident (#59) of two residents reviewed for activities resulting in the potential for depression, boredom, and feelings of lack of self-worth. Findings Include: Resident #59 (R59) Review of the medical record revealed R59 was admitted to the facility on [DATE] with diagnoses that included hypertension, type two diabetes, major depressive disorder, unspecified dementia, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/23 revealed R59 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R59 required extensive assistance of one person for dressing and total dependence for transferring and toileting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate safety measures to ensure resident safety for one resident (R309) of four residents reviewed for accidents and hazards, resulting in R309's repeat falls post surgical repair with re-fracture and increased likelihood for additional accidents and/or injuries.

Inspectors wroteThis citation pertains to intake MI00138710. Based on observation, interview, and record review, the facility failed to provide treatment and services to restore as much normal bowel and bladder function as possible in one of two residents reviewed for bowel and bladder incontinence (Resident 149#), resulting in continued or worsened incontinence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform nutritional assessments and implement nutrition interventions for two (Resident #109 and Resident #146) of six reviewed, resulting in the potential for continued weight loss and a decline in nutritional status.

Inspectors wroteBased on interview and record review the facility failed to ensure three out of six Certified Nurse Aids (CNA) have completed a yearly competency/skills check list resulting in the potential for compromised resident care and unmet needs. Findings Included: In an interview on 8/30/2023 at 10:13 AM, CNA W stated that she had been telling Director of Nursing (DON) B, and even wrote a letter that she needed to get her skills competency checklist completed. CNA W stated she also told Unit Manager X, and she had been telling them for three months that her skills check list was due at the end of the month. In an interview on 8/30/2023 at 2:18 PM, [NAME] President of Human Resources (VP/HR) D stated that the CNA skills competency checklist was to be completed yearly. VP/HR D said it must be done in person. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the use of an antipsychotic for one (Resident #144) and attempt non-pharmacological interventions prior to the use of a PRN (as needed) antianxiety medication for one (Resident #68) of five reviewed, resulting in the potential for adverse reactions and unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when three medication errors were observed from a total of 34 opportunities for three residents (Resident #4, Resident #70, and Resident #103) of six residents reviewed for medication administration, resulting in a medication error rate of 8.82% and the potential for adverse reactions/side effects.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin according to physician orders in one of five residents reviewed for medication administration (Resident #59), resulting in an increased risk of hypoglycemia or hyperglycemia.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biological's stored in a medication cart were securely locked while the cart was unattended, resulting in the potential for residents to access medications. Findings Included: In an observation on the 200 hall on 8/29/2023 at 11:16 AM, Licensed Practical Nurse (LPN) S was observed in the hall administering medications to a resident. The medication cart was was observed to be located by room [ROOM NUMBER], and LPN S was located by rooms 209-213. The medication cart was observed to be left unlocked while LPN S was down the hall administering medications to a resident. The time the cart was unattended was approximately 4 minutes. [...]

Inspectors wroteThis citation pertains to intake MI00138710. Based on observation, interview, and record review, the facility failed to provide food and drink per assessment and individualized care plan, in 2 of 19 reviewed for dining (Resident #51 & #149), resulting in the potential for choking, decreased food acceptance, protein deficiency, and burns (Resident #51).

Inspectors wroteBased on observation, interview, and record review the facility failed to meet resident individualized food preferences in one (Resident #208) of 19 residents reviewed, resulting in the potential for weight loss, decreased meal enjoyment and/or frustration. Findings Include: Resident #208 (R208) According to the facility's admission record, R208 admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver disease/excess abdominal fluid, chronic obstructive pulmonary disease (COPD, lung disease), type 2 diabetes, and hyperlipidemia (high cholesterol). A review of the MDS (Minimum Data Set) dated 08/28/2023 reflected R208 had a brief interview for mental status (BIMS), a short performance based cognitive screen for nursing home residents, score of 14 (13-15, cognitively intact). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive equipment for one (Resident #146) of 19 reviewed, resulting in the potential for decreased independence with drinking.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate hand hygiene and infection control practices during lunch time meal pass, resulting in missed opportunities for hand hygiene, improper hand hygiene techniques, and the potential for the spread of infection. Findings Include: In an observation on 08/28/23 at 12:11 PM, an observation was made of a staff member grabbing a plate containing a resident's lunch and delivering the plate to the resident. The staff member returned to the kitchen and grabbed another resident's plate containing their lunch and proceeded to deliver to a different resident without performing hand hygiene in between residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer a pneumococcal immunization timely to one (Resident #146) of five reviewed for immunizations, resulting in the potential to contract a pneumococcal infection, and/or experience serious illness or complications.

Inspectors wroteBased upon interview and record review, the facility failed to ensure that the nurse staffing data was posted daily resulting in the potential for all 171 residents as well as visitors to be uninformed of the facility's staffing information.