Iosco County Medical Care Facility

In the surveyor’s words

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

• Actual harm, isolatedF686Jan 8, 2026

  Based on observation, interview and record review, the facility failed to implement interventions to prevent pressure ulcer development for two residents(R9 and R22) of two residents reviewed, resulting in R9 developing an unstageable DTI and Resident R22 developing a stage II (partial thickness loss of first and second layer of skin) and unstageable DTI, unnecessary pain, and the likelihood for infection and decline in overall health status.Findings include: Resident #9 On 1/6/26 at 10:38 AM, Resident #9 was observed sitting in a wheelchair in the central area of the facility. Resident #9 was unable to provide meaningful responses to questions when asked. A pull tab alarm was observed on the Resident's wheelchair and was connected to the back of their shirt. […]

• Actual harm, isolatedF686Nov 21, 2023

  Based on observation, interview, and record review, the facility failed to implement and operationalize a comprehensive skin management program and implement meaningful and timely interventions to prevent pressure ulcer (wounds caused by pressure) development for two residents (Resident #9 and Resident #24) of four residents reviewed, resulting in inconsistent, inaccurate, and unclear wound documentation and assessment, lack of implementation of meaningful, timely, and revised, interventions, care coordination, Resident #9 developing a Stage 3 (full thickness tissue loss with exposed subcutaneous tissue), Resident #24 developing Stage 2 (partial thickness tissue loss presenting as an open ulcer) and unstageable pressure ulcers (unknown depth), and the likelihood for lack of timely and… […]

• Actual harm, isolatedF689Nov 21, 2023

  37668 Deficient Practice Statement (DPS) One: This Citation Pertains to Intake Number: MI00139609. Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures to ensure appropriate supervision to prevent falls for one resident (Resident #24) of two residents reviewed, resulting in Resident #24 (R24) being left unattended in the Activity Room, falling, and suffering a right hip fracture, unnecessary pain, and the likelihood for decline in overall health status. […]

• Actual harm, isolatedF689Aug 20, 2021

  This Citation Pertains to Intake Number MI 654. Based on interview and record review, the facility failed to operationalize policies and procedures to ensure safe transfers and ambulation for one resident (Resident #197) of three residents reviewed for accidents, resulting in a lack of implementation of the facility policy/procedures and standards of practice for transferring and ambulation. Resident #197 suffering a fall with a subdural hematoma (brain bleed) which necessitated emergency transfer to the hospital, mechanical ventilation, and death. […]

• No harm, potential for more than minimal, widespreadF865Jan 8, 2026

  Based on interview and record review, the facility failed to have policies and procedures for data collection, analysis and feedback procedures for 21 residents sampled of 49 residents, resulting in only one sheet of paper policy for the quality assurance program when the surveyor requested the program to review and the contracted pharmacy services failed to attend the quality assurance quarterly meetings for the last six months. Findings include: Quality assurance Task: Record review of the facility 'Quality Assurance Program' policy dated 12/13/2016 signed by a previous nursing home administrator, revealed that it is the policy of the facility to actively participate in a formalized and written Quality Assurance (QA)/ Quality Assurance Process Improvement (QAPI) program. […]