200 Sand Creek Highway, Adrian, MI 49221 · Lenawee County · (517) 263-6794
113 certified beds, about 111 residents a day · Government - County · Medicare and Medicaid since 1973
CMS Care Compare ratings, data as of September 1, 2026 · CCN 235224 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on March 19, 2026, inspectors cited 7 health deficiencies (the Michigan average is 9.9, the national average 9.2).
Of 24 health citations since October 2023, 5 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $15,593 in the last three years; the largest was $15,593, and the latest is dated November 16, 2023.
Nurses and nurse aides worked 5.33 hours per resident per day, against 3.99 across Michigan and 3.86 nationally. Registered nurses accounted for 0.53 of those hours.
50.5% of nursing staff left within the year CMS measured (Michigan average 44.1%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 24 health citations on file.
Inspectors wroteThis Citation Pertains to Intake 2997912. Based on observations/interviews and record review, the facility failed to protect the resident's right to be free from of physical and mental abuse perpetrated by staff for one resident (Resident #2) of three reviewed. Resulting in R2 being abused by staff.
Inspectors wroteThis Citation Pertains to Intake 2997912. Based on observation, interview and record review the facility failed to ensure one resident (resident #2) was free from physical restraints, resulting in anger frustration.
Inspectors wroteThis Citation Pertains to Intake 2997912. Based on observations/interviews and record review, the facility failed to preserve the dignity and right to make choices including the refusal of care for one resident (Resident #2) of three reviewed.
Inspectors wroteThis Citation Pertains to Intake 2997912. Based on observations, 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.for one resident (Resident #2) of three reviewed.
Inspectors wroteThis Citation Pertains to Intake 2997912Based on observation, interview and record review, the facility failed to ensure the protection of residents from abuse for one (Resident #2) of three residents reviewed, resulting in the potential for continued abuse.
Inspectors wroteBased on interview and record review, the facility failed to maintain record of successful completion of a State-approved paid feeding assistant training course for 6 of 12 paid feeding assistants. Review of the lists provided by the facility, the facility had 12 staff who were Paid Feeding Assistants and 9 residents who were approved for the Paid Feeding Assistant program. In an interview on 03/19/26 at 12:55 PM, Director of Nursing (DON) B reported the facility was only able to locate the documentation of completion of a State-approved paid feeding assistant training course for 6 of the 12 staff who worked as Paid Feeding Assistants. [...]
Inspectors wroteBased on interview, observation and record review the facility failed to assess one resident (R121) out of three to self-administer her medications safely and independently. Findings IncludeResident 121 (R121)Review of the medical record reflected that R121 was admitted to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, pain in her right and left shoulders, Heart Failure, Acute Kidney Failure, Anxiety, Depression and shortness of breath. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R121 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R121 needed minimum assistance with showering, personal care, getting dressed and putting on footwear, however, this portion was not completed at this time. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to protect personal, private and confidential information for one resident (R121) of three resident's protected information. Findings Include:Resident #121 (R121)Review of the medical record reflected that R121 was admitted to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, pain in her right and left shoulders, Heart Failure, Acute Kidney Failure, Anxiety, Depression and shortness of breath. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R121 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) Assessment timely for one (R13) of 23 reviewed.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement a restorative maintenance program for one (R3) of one reviewed.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication rate was less than 5% when two medication errors were observed form a total of 30 opportunities for one resident (#121) of three reviewed for medication administration, resulting in a mediation error rate of 6.67 %.Findings IncludeResident #121 (R121)Review of the medical record reflected that R121 was admitted to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, pain in her right and left shoulders, Heart Failure, Acute Kidney Failure, Anxiety, Depression and shortness of breath. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R121 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. [...]
Inspectors wroteBased on observations during medication administration the facility failed to provide hand hygiene for one resident (R121) out of three residents observed during medication administration. Findings IncludeResident #121 (R121)Review of the medical record reflected that R121 was admitted to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, pain in her right and left shoulders, Heart Failure, Acute Kidney Failure, Anxiety, Depression and shortness of breath. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R121 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R121 needed minimum assistance with showering, personal care, getting dressed and putting on footwear, however, was not completed at this time. [...]
Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate the alleged sexual abuse on one resident (R2) of one resident investigated for abuse. Linked to intake 2645136Findings IncludeResident #2 (R2)Review of the medical record reflected that R2 was admitted to the facility on [DATE]. Diagnoses of Congestive Heart Failure, Stroke, Traumatic Brain Injury, Dysphagia (difficulty swallowing), Major Depression, High Blood Pressure, Bi-Polar, weakness and unsteady on her feet. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/2025 revealed R2 had a Brief Interview of Mental Status (BIMS) of 07 (Moderate to severe cognition impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 needed assistance of 1 person with personal care. [...]
Inspectors wroteThis citation pertains to Intake 2621377. Based on observation, interview, and record review, the facility failed to respect the right to privacy for one (R1) of three reviewed.
Inspectors wroteThis citation pertains to intake MI00153332. Based on observation, interview and record review, the facility failed to ensure a transfer was performed according to the plan of care for one (R3) of three reviewed, resulting in R3 being lowered to the floor and sustaining a fracture.
Inspectors wroteThis citation pertains to intake MI00153420 Based on observation, interview and record review the facility failed to ensure that three residents (R4, R6, R7) were free from non-physician ordered chemical restraints imposed for purposes of staff convenience of five residents reviewed.
Inspectors wroteThis citation pertains to Intake # MI00143838 Based on observation, interview, and record review, the facility failed to protect resident property in 1 of 3 residents reviewed for misappropriation of property (Resident #2), resulting in feelings of sadness and potential mistrust.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff had proper certification for Cardiopulmonary Resuscitation (CPR- medical interventions used to restore circulatory and/or respiratory function that has ceased), including 2 (Nurses K and I) of 6 reviewed for CPR certification, resulting in the likelihood of residents not receiving adequate life sustaining treatments in the event of a sudden change in condition, potentially affecting all residents choosing to receive CPR. Review of the medical record reflected Resident #111 (R111) was admitted to the facility on [DATE], with diagnoses that included essential hypertension, Type 2 diabetes with diabetic neuropathy, sleep apnea, and acute respiratory failure. The Minimum Data Set (MDS) history reflected R111 died in the facility on 10/19/23. [...]
Inspectors wroteThis citation pertains to intake numbers MI00136522 and MI00135497. Based on interview and record review the facility failed to ensure for two out of six residents (Residents 312 and 313) allegations of abuse were reported immediately to the abuse coordinator and state agency resulting in the potential for alleged and/or actual abuse to not be reported. Findings Included: Resident #313 (R313): R313 no longer resided at the facility. Per R313's Electronic Medical Record (EMR) R313 was [AGE] years old with a diagnosis of dementia. Review of a Facility Reported Incident (FRI) revealed Resident Service Aid (RSA) P was attending a training class on 1/19/2023, and when abuse and neglect were discussed RSA P recalled an incident that had occurred on 1/11/2023. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure a comprehensive care plan was in place for one out of 22 residents (Resident 313), resulting in the potential for care needs to not be met. Findings Included: Resident #313 (R313) no longer resided at the facility. Per R313's Electronic Medical Record (EMR) R313 was [AGE] years old with a diagnosis of dementia. Review of a Facility Reported Incident (FRI) revealed Resident Service Aid (RSA) P reported to RN M that on 1/11/2023 she was sitting at the nurses' station when she overheard RSA Q say to R313, (R313) you stop that shit; there is no cat in there. So annoying, and then walk out of R313's room. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an assessment, properly document a critical medical emergency, and ensure cardiopulmonary resuscitation (CPR) was performed timely by competent staff and according to standards of practice for one (Resident #111) of two reviewed for quality of care, resulting in delayed identification of a change in condition, a delay in CPR, ineffective CPR efforts, and ultimately death in R111. Findings Include: Review of the medical record reflected Resident #111 (R111) was admitted to the facility on [DATE], with diagnoses that included essential hypertension, Type 2 diabetes with diabetic neuropathy, sleep apnea, and acute respiratory failure. The Minimum Data Set (MDS) history reflected R111 died in the facility on 10/19/23. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate and promptly implement effective interventions to prevent falls with injuries in one of one residents reviewed for accidents (Resident #34), resulting in fall with fracture and pain.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure grievances were readily accessible in a public location as reported by seven of seven residents during a confidential Resident Council meeting, potentially resulting in unresolved concerns of residents and visitors, unmet needs of residents and their wish to remain anonymous if desired.
Inspectors wroteThis citation pertains to intakes MI00136626 and MI00140194. Based on observation, interview, and record review the facility failed to protect the residents' right to be free from sexual abuse by a resident for two residents (Resident #6 and Resident #3) of six reviewed, resulting in Resident #6 being sexually abused by Resident #5 which caused increased tearfulness, anxiety, and emotional distress and Resident #3 being sexually abused by Resident #4.
3 fire safety citations on file: 3 on March 19, 2026.
| Date | Penalty | Amount or length |
|---|---|---|
| November 16, 2023 | Fine | $15,593 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Michigan | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.33 | 3.99 | 3.86 |
| Registered nurses | 0.53 | 0.78 | 0.69 |
| All nursing staff on weekends | 4.65 | 3.50 | 3.42 |
| Nurse aides | 3.69 | ||
| Licensed practical nurses | 1.11 | ||
| Nursing staff turnover (share who left in a year) | 50.5% | 44.1% | 45.8% |
| Registered nurse turnover | 35.0% | 39.2% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.50 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.60 on weekdays and 4.65 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.95 in April to June 2025 to 5.33 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.33 | 0.53 | 5.60 | 4.65 | 0.6% | 0 of 90 | 111 |
| Oct to Dec 2025 | 5.22 | 0.51 | 5.45 | 4.63 | 4.0% | 0 of 92 | 111 |
| Jul to Sep 2025 | 5.14 | 0.53 | 5.39 | 4.52 | 7.4% | 0 of 92 | 111 |
| Apr to Jun 2025 | 4.95 | 0.56 | 5.23 | 4.25 | 6.2% | 0 of 91 | 112 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Michigan, Jan to Mar 2026 | 3.95 | 0.70 | 4.14 | 3.45 | 3.3% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Michigan, all employers | |||
| CNAs (nursing assistants) | $19.03 | $18.35 to $21.59 | 43,290 |
| LPNs and LVNs | $31.47 | $29.83 to $35.52 | 10,880 |
| Registered nurses | $45.34 | $39.46 to $49.74 | 104,950 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Michigan | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 10.9 | 10.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.0 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.1 | 3.0 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.5 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 14.4 | 12.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.6 | 5.1 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 5.2 | 14.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 10.7 | 24.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 13.4 | 11.7 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 1.8 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Lenawee Medical Care Facility's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (62.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
62.8% this home
Better than the national rate
US median of homes 51.5% · Michigan: 89 better, 22 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 161 eligible stays.
10.9% this home
No different from the national rate
US median of homes 10.7% · Michigan: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 177 eligible stays.
6.3% this home
No different from the national rate
US median of homes 7.1% · Michigan: 1 better, 1 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 87 eligible stays.
51.5% this home
Median of homes: Michigan57.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 33 residents counted.
0.0% this home
Median of homes: Michigan0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 37 residents counted.
2.2% this home
Median of homes: Michigan1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 37 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Michigan99.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 7 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: LENAWEE MEDICAL CARE FACILITY.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Lenawee County | 5% or greater direct ownership interest | Organization | 100% | 09/01/1970 |
| Elledge, Sara | Managing control - governing body | Individual | 12/06/2017 | |
| Graham, Amy | Managing control - governing body | Individual | 04/14/2025 | |
| Jones, Kristie | Managing control - governing body | Individual | 11/01/2021 | |
| Jones, Lindsey | Managing control - governing body | Individual | 06/18/2023 | |
| Macnaughton, Thomas | Managing control - governing body | Individual | 09/18/2015 | |
| Reilly, Jennifer | Managing control - governing body | Individual | 06/17/2024 | |
| Tuckey, Erin | Managing control - governing body | Individual | 09/27/2021 | |
| Vernier, Kirk | Managing control - governing body | Individual | 06/18/2023 | |
| Williamson, Brandy | Managing control - governing body | Individual | 08/20/2018 | |
| Lenawee County | Operational/managerial control | Organization | 09/01/1970 | |
| Blevins, Christina | Operational/managerial control | Individual | 09/01/2025 | |
| Scarborough, Joyce | Operational/managerial control | Individual | 11/18/2024 | |
| Concept Rehab, Inc. | Adp of the SNF | Organization | 01/01/2024 | |
| Lenawee County | Adp of the SNF | Organization | 09/01/1970 | |
| Maner, Costerisan & Ellis, PC | Adp of the SNF | Organization | 01/01/2025 | |
| Michigan Post-Acute Medical Services 1 PC | Adp of the SNF | Organization | 01/01/2024 | |
| Morrison Management Specialists Inc | Adp of the SNF | Organization | 01/17/2022 | |
| Blevins, Christina | Adp of the SNF | Individual | 09/01/2025 | |
| Macnaughton, Thomas | Adp of the SNF | Individual | 09/18/2015 | |
| Tuckey, Erin | Adp of the SNF | Individual | 11/13/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Michigan. NursingHomeClear cannot take or act on complaints.