Isabella County Medical Care Facility

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF552Mar 18, 2026

  Based on interview and record review, the facility failed to educate and provide informed consent of psychotropic medications for 3 residents (R1, R69, and R70) out of 5 reviewed. Findings include: R69 Review of an admission Record revealed R69 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and depression. Review of R69's Physician's Orders active 3/18/2026 revealed R69 was taking fluoxetine HCI (used to treat depression, anxiety, and several other mental health conditions) and bupropion HCI (used to treat depression and other mental health conditions). […]

• No harm, potential for more than minimal, patternF756Jan 16, 2025

  Based on interview and record review, the facility failed to ensure that monthly pharmacy reviews were conducted for 5 of 5 residents (R3, R16, R28, R46, & R66) reviewed for monthly pharmacy medication regimen reviews, resulting in residents medications not being reviewed and the potential for an adverse outcome from medications and/or lack of assessment and monitoring of medications. Findings include: A review of the facility's Drug/Medication Regiment Review for All Residents policy, last revised 8/22, revealed the Medication Regimen Review (MRR) is a thorough evaluation of the medication regiment of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and potential risks… […]

• No harm, potential for more than minimal, patternF583Aug 19, 2021

  Based on observation, interview, and record review, the facility failed to maintain confidentiality of resident medical records for 8 residents (Resident #10, Resident #19, Resident #28, Resident #52, Resident #54, Resident #62, Resident #65, and Resident #117), resulting in the potential for disclosure of residents' personal and confidential information to unauthorized individuals and the potential for residents' privacy of protected health information/personally identifiable information (PHI/PII) and Health Insurance Portability and Accountability Act (HIPAA) information being violated. Findings include: During an observation on 08/17/21 at 11:30 AM, the 2 South Medication Cart computer screen was open and visible to anyone walking by the nurse's station. […]

• No harm, potential for more than minimal, patternF761Aug 19, 2021

  Based on observation, interview, and record review, the facility failed to properly store and label medications for 1 of 3 medication carts reviewed (2 South Medication Cart), resulting in the potential for misappropriation and residents receiving the wrong medications. Findings include: During an observation on 8/17/21 at 12:25 PM, the 2 South Medication Cart, including the narcotics drawer, was observed to be unlocked. Staff were not visibly present in the area. During an interview at the 2 South Medication Cart on 08/17/21 at 12:30 PM, Licensed Practical Nurse (LPN) E stated, Oh. The cart is unlocked. […]

• No harm, potential for more than minimal, isolatedF758Nov 16, 2023

  Based on interview and record review, the facility failed to follow their policies and procedures and provide documentation justifying psychotropic medication for 1 (Resident #2), out of 5 residents reviewed for psychotropic medications, resulting in the potential for unnecessary medication orders/administration. Findings include: Review of a policy titled Use of Psychotropic Medication last revised on 5/22 revealed: PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. […]