Eaton County Medical Care Facility

In the surveyor’s words

From the most serious findings on record at Eaton County Medical Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 1, 2023

  Based 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. Findings include: Review of the facility, Skin Care Policy, dated 2/22, reflected, It is the policy of the [named facility] to routinely protect residents/patients from skin breakdown and injury. […]

• Actual harm, isolatedF689Dec 7, 2021

  Based on observation, interview and record review, the facility failed to implement new interventions to prevent a fall with major injury in one of seven residents reviewed for abuse (Resident #5), resulting in hospital transfer, pain, two rib fractures, and other injuries. Findings include: Resident #5 (R5) R5's Minimum Data Set (MDS) assessment dated [DATE] indicated he was admitted to the facility on [DATE], his Brief Interview for Mental Status, a short performance-based cognitive screener for nursing home (NH) residents score was 00 (,d+[DATE] Severe Impairment). The same MDS assessment indicated R5 was not steady walking and required limited assistance of one person when walking in his room or in the corridor. […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2026

  Based 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.Findings include:On 02/10/2026 at 10:20 A.M., An initial tour of the food service was conducted with Culinary Services Manager E. The following items were noted:Walk-In Freezer: The air curtain strips were observed (cracked, brittle, missing). The entrance door gasket was also observed (worn, torn, etched). Frozen water condensation droplets and severe heavy frost deposits were further observed on the walk-in freezer ceiling, adjacent to the refrigeration fan unit. The effected area measured approximately 8-feet-wide by 8-feet-long. […]

• No harm, potential for more than minimal, widespreadF812Dec 20, 2024

  Based 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. Findings include: During a tour of the kitchen, starting at 12:54 PM on 12/17/24, it was observed that a box of vegetables and large bag of potatoes were found stored on the floor of walk-in cooler three. An interview with Head Chef (HC) F found that deliveries come Monday and Thursday. During a tour of the walk-in freezer, at 1:42 PM on 12/17/24, it was observed that multiple boxes of food product were found stored on the floor such as vegetables and buttermilk biscuits. […]

• No harm, potential for more than minimal, widespreadF880Dec 20, 2024

  Based 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. Findings include: During a tour of the facility, at 10:35 AM on 12/18/24, an interview with Maintenance (M) I found that Building Services Director (BSD) H handles the Water Management Plan (WMP). During a tour of Unit A soiled utility room, at 10:40 AM on 12/18/24, it was observed that water in the hopper was found to be low in the bowl. […]