Sanilac Medical Care Facility

Inspectors wrotePast Non-Compliance (PNC) was identified during the investigation of the deficient practice and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 01/28/2026. Based on observation, interview and record review, the facility failed to ensure resident safety when care-planned interventions were not followed during a transfer to a wheelchair for one resident (Resident #1) of four residents reviewed for an injury of unknown origin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure cleanliness of the water system and the use of appropriate backflow prevention on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to uncleanliness and a potential backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate staffing to meet the care needs of the residents for a confidential group of residents, and Residents #10, # 50, #52, and #89, resulting in long call light wait times, scheduled activities being cancelled and delayed resident care.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent verbal abuse for one (Resident #40) of 19 residents reviewed for abuse, resulting in refused care, frustration with the likelihood of increased behavioral disturbances.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening/Annual Resident Review (PASARR) form DCH-3877 and DCH-3878 were completed for one resident (Resident #67) of two residents reviewed for PASARR evaluation. Findings Include: A review of Resident #67's medical record revealed an admission into the facility on 7/30/2003 and readmission on [DATE] with diagnoses that included history of traumatic brain injury, anxiety, mood disorder, mental disorder due to known physiological condition, dementia and need for assistance with personal care. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognitive skills for daily decision making and was dependent on helper for activities of daily living and mobility. A review of Resident #67's medical record revealed PASARR Level I Screening dated 10/12/2023. [...]

Inspectors wroteBased on interview and record review the facility failure to ensure availability and accurate documentation for Lexapro (antidepressant medication) for one resident (34) of 5 reviewed for medication management, resulting in Resident #34 not receiving her medications for approximately three weeks and imprecise medication administration documentation. Findings Include:On 8/20/2025 at approximately 9:15 AM, a review was conducted of Resident #34's medical record and it indicated she admitted to the facility on [DATE] with diagnoses that included Dementia, Hyperlipidemia, Hypertension, Adjustment Disorder with mixed anxiety and depressed mood and Anxiety. Further review revealed the following:Physician Orders:Lexapro Oral Tablet 5 MG (milligram)- Give one tablet by mouth one time a day for agitation, irritability, depressed mood. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure restorative therapy services were provided for two Residents (#36 and 50), of three reviewed for limited range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an indwelling urinary catheter bag and tubing were not in contact with the floor during transport of the Resident through the dining area and hallway and when the Resident was seated in their wheelchair in their room, for one Resident (#2), of two reviewed for indwelling urinary catheters.

Inspectors wroteThis Citation pertains to Intake Numbers MI00140471 and MI00142854. Based on observation, interview, and record review the facility failed to ensure comprehensive documentation and evaluation to prevent the development of an unstageable facility-acquired pressure ulcer for one resident (Resident #63) of seven residents reviewed for alterations in skin integrity, resulting in Resident #63 acquiring and developing an unstageable pressure ulcer.

Inspectors wroteThis Citation pertains to Intake Numbers MI00144103 and MI00144517. Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place, interventions were followed and supervision was provided to prevent falls with injury for 2 residents (Resident #38, and Resident #44) of 5 residents reviewed for falls, resulting in Resident #38 falling during a transfer, having pain and a decline in transfer status to a Hoyer lift, and Resident #44 sustaining fractures in her right foot during a transfer. Findings Include: Resident #44: Accidents: On 6/25/24 at 10:56 AM, Resident #44 was observed sitting in a wheelchair in her room. She was alert and talkative. She said she broke some of her toes on her right foot during a transfer in the bathroom. [...]

Inspectors wroteThis Citation Pertains to Intake MI00142721 Based on observation, interview and record review, the facility failed to administer a nebulizer treatment according to professional standards for Resident #35, administer medications as prescribed by the physician for Resident #224 and Resident #322, and ensure standards of practice for appropriate diagnosis and use of multiple psychotropic and antipsychotic medications for Resident #377, of seven residents reviewed for medication administration and five residents reviewed for medication regimen review, resulting in Resident #35 not assessed prior to administration or monitored during the duration of a nebulizer treatment with the potential for complications to go unnoticed, untreated or not receive the prescribed amount of medication used to treat lung disease, the potential for exacerbation of medical conditions for Resident #35, Resident [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program encompassing outcome and process surveillance and failed to ensure readily available hand hygiene supplies, hand hygiene performance and catheter care per professional standards of practice, resulting in a lack of tracking of potential infections, a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for the spread of microorganisms and illness to all 71 facility residents.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain informed consent prior to initiating antipsychotic medication for two residents (Resident #25 and Resident #32) of three residents sampled for antipsychotic medication use, resulting in the resident and/or responsible party not being informed of the risk versus benefit of antipsychotic medication use prior to initiation.

Inspectors wroteBased on observation, interview and record review the facility failed to accommodate resident choice in Guardianship for 1 resident (#16) of 27 residents reviewed for resident choice, resulting in Resident #16 becoming upset and worried that she would not have someone to look out for her when her wishes were not considered. Findings Include, Resident #16 Choices On [DATE] at 9:30 AM, during a tour of the facility, Resident #16 was observed getting ready for the day. She was sitting in her wheelchair, dressed and preparing to attend an activity in the dining room. She said she spent most of her day in the facilities activities and that is what she enjoyed doing. She said she had some issues to discuss. Resident #16 said she was upset because the facility was suing her to remove her Guardian, who is her sister and replace her with a public guardian. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for three residents (Resident #2, Resident #6, and Resident #32), of 30 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #2: Accidents On 6/25/2024 at 12:56 PM, Resident #2 was observed sitting in a wheelchair in his room. He was alert but did not answer any questions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and had multiple discharges and readmissions with the most recent readmission on [DATE] with diagnoses: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00140471. Based on observation, interview and record review the facility failed to ensure nail care was routinely provided for one resident (Resident #68) of 4 residents reviewed for Activities of Daily Living (ADL), resulting in Resident #68 having long, soiled, fingernails and long, cracked toenails. Findings Include, Resident #68 Activities of Daily Living On 6/25/24 at 12:51 PM, during a tour of the facility, Resident #68 was observed to have her left foot with long, cracked toenails. Her fingernails were extremely long and soiled. The resident said she couldn't trim them herself, but her granddaughter helped trim a couple of her toenails, although she couldn't trim 2 of them because the toenails were too long and difficult to cut. When asked if the staff assisted her, she said they had not trimmed them in a while. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oxygen per physician's order and store nebulizer equipment sanitarily for one resident (Resident #35) of three residents reviewed for respiratory needs, resulting in oxygen administration provided of improper dosage with the likelihood of decreased oxygenation and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure coordination of dialysis care for one resident (Resident #26) of 1 resident reviewed for dialysis services, resulting in a lack of assessment for the left arm Dialysis fistula, dressing and site, resulting in the potential for unidentified complications. Findings Include: Resident #26: Dialysis A record review Face sheet and Minimum Data Set (MDS) assessment for Resident #26 indicated the resident was admitted to the facility on [DATE] with several discharges to the hospital and readmissions. The latest readmission was 2/6/2024 with diagnoses: history of a stroke, right side weakness, kidney stones, respiratory failure, COPD, diabetes, chronic kidney disease, renal dialysis dependence, morbid obesity, and heart failure. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% when two medications were omitted for Resident #224 and nine medications were not administered timely for Resident #224 and Resident #322, from a total of 42 opportunities, resulting in a medication administration error rate of 26.19% with the potential for adverse reactions or exacerbation of conditions related to the omission of the medications or medications not given timely.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications, including a narcotic medication, properly during the medication administration task of the survey, resulting in improper medication storage with the potential of drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive antibiotic stewardship and monitoring program for two residents (Resident #2 and Resident #21) of two residents reviewed, resulting in inappropriate use of antibiotics.

Inspectors wroteThis Citation pertains to Intake Numbers MI00142202 and MI00144560. Based on interview and record review, the facility failed to assess and monitor hydration status timely and notify family for one resident (Resident #376) of one resident assessed for Intravenous (IV) fluids, resulting in an undocumented amount of IV fluids administered, no family notification and ultimately hospitalization.

Inspectors wroteThis Citation pertains to Intake Number MI00142721. Based on interview and record review, the facility failed to operationalize policies and procedures to mitigate potential adverse consequences of psychotropic medications for one resident (Resident #377) of two residents reviewed for behaviors, resulting in a lack of baseline laboratory testing prior to the initiation of multiple psychotropic medications, ongoing in facility monitoring, and identification of potential adverse consequences in a timely manner with Resident #377 suffering decreased liver and kidney function, and a decline in overall health.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that food preparation and kitchen equipment were maintained in a sanitary manner and in good working condition, and 2) Failed to ensure that kitchen dish machine temperature logs were completed, resulting in an increased potential for food borne illness with possible hospitalization and with the potential to affect the census of 74 residents who consume nutrition from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to effectively conduct a Quality Assurance and Performance Improvement program for all residents residing within the facility, resulting in 1) A physician prescribing antibiotics prior to laboratory results, 2) Inconsistent narcotic counts, 3) Resident Council grievances, 4) Infection rate action plans and 5) Call lights within reach for residents' use, all with the likelihood for residents' frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dignity by not ensuring that 7 residents' (Resident #2, Resident #22, Resident #27, Resident #43, Resident #64, Resident #70, and Resident #128) call lights were within reach, of 24 resident's sampled, resulting in decreased safety while left in the room alone without a way to contact staff in an emergency, and feelings of anger, frustration, decreased dignity and fear of being left alone. Findings Include: Review of the facility Call Button/Activator: Accessibility and Timely Response/Resident Call Pagers (includes call lights), reported This policy is to assure residents to call for assistance. Assess the arrangement of furniture in the resident's room to assure proper call button/activator placement. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly identify and treat Urinary Tract Infections (UTI) for five residents (Resident #11, Resident #13, Resident #49, Resident #59, and Resident #176), resulting in the likelihood for urinary tract infections to be mistreated with prolonging of illnesses or hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to obtain adequate indication for the use of treatment with antibiotics for 5 residents (Resident #11, Resident #13, Resident #49, Resident #59, and Resident #176), resulting in the likelihood for urinary tract infections to be mistreated and prolonged illnesses or hospitalizations.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that controlled medication shift change sheets, dated 06/23, had the correct daily count for 2 medication carts (Cart 300 and Cart 600/800), and 2) Failed to ensure a clean and sanitary medication cart (Cart 600/800), resulting in the likelihood for missing narcotics, residents not receiving pain medications (narcotics) per orders and increased pain for a census of 74 residents. Findings Include: Observation of the 600/800 medication cart accompanied by Nurse, LPN B done on 6/22/23 at 10:19 a.m., revealed crushed medications and papers in the bottom of the second drawer. During an interview done on 6/22/23 at 10:30 a.m., Nurse B stated The night nurse cleans it (medication carts). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent moisture associated skin damage for one resident (Resident #49), resulting in pain and discomfort and the likelihood for the development of a pressure injury to the skin.

Inspectors wroteBased on interview and record review, the facility 1) Failed to ensure that the Infection Control program analyzed monthly resident and staff infections completely and accurately, and 2) Failed to put complete COVID precautions in place (stopping the use of fans turned on in the hallways of the main unit) on 06/27/23, when 5 residents (Resident #1, Resident #22, Resident #27, Resident #35 and Resident #129) became positive with COVID-19, resulting in the likelihood for cross contamination of medications in the medication cart, cross contamination of COVID from resident-to-resident, and the likelihood of an increase in resident infections with resident illnesses and hospitalizations. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility 1) Failed to ensure monitoring and analyzing of resident illnesses and antibiotic usage, and 2) Failed to ensure that resident infections met the accepted McGeer criteria, indicating that signs and symptoms were documented as meeting the criteria, resulting in the likelihood of resident infections not meeting the McGeer definition of infection and not meeting the criteria for antibiotic usage, adverse side effects from antibiotics, and over antibiotic usage with the possibility for antibiotic resistance, and increased resident illnesses. Findings Include: Review of the facility Resident Infections for the Month of March 2023, revealed a total of 17 resident infections with antibiotic usage of 19 (non-COVID) resident infections that did not meet the McGeer criteria for antibiotic usage. [...]