Lapeer County Medical Care Facility

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 1, 2026

  Based on observation, interview and record review, the facility failed to prevent two unstageable pressure ulcers (a severe wound with full-thickness tissue loss, fully covered by slough or eschar, making its true depth hidden) for one resident (Resident #164) of three residents reviewed for pressure ulcers, resulting in bilateral heel pressure ulcers. Findings include.Resident #164:On 3/30/2026, at 10:45 AM, Resident #164 was propelling in the hallway in their wheelchair. There were no wheelchair pedals and the residents' heels were slightly dragging on the floor while they propelled. Resident #164 had on socks. […]

• Actual harm, isolatedF689Dec 19, 2023

  Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident # 401) of 6 residents reviewed for accidents and falls, resulting in Resident #401 experiencing multiple falls and sustaining several fractures. Findings Include: Resident #401: Accidents: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #401 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, anxiety, depression, arthritis, and history of urinary tract infections. […]

• Actual harm, isolatedF684Feb 22, 2023

  This Citation Pertains to Intake Number MI00133837. Based on interview and record review, the facility failed to assess and monitor a resident with a wound infection, urinary tract infection and elevated temperatures for one resident (Resident #1) of three residents reviewed for changes in condition, resulting in hospitalization , wound infection, sepsis, deterioration of health status and wellbeing and subsequent death. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE], readmission on 7/22/22 and transferred to the hospital on 11/1/22. […]

• Actual harm, isolatedF686Feb 22, 2023

  This Citation Pertains to Intake Number MI00133837. Based on interview and record review, the facility failed to prevent, monitor and treat a facility-acquired pressure ulcer for one resident (Resident #1) of three residents reviewed for pressure ulcers, resulting in the worsening of the pressure ulcer to a Stage IV, infection, sepsis, a deterioration of health and wellbeing and subsequent death. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE], readmission on 7/22/22 and transferred to the hospital on 11/1/22. […]

• Actual harm, isolatedF604Sep 22, 2022

  Based on observation, interview and record review, the facility failed to ensure physical restraints were not utilized for staff convenience and to unnecessarily inhibit freedom of movement for one resident (Resident #85) of two residents reviewed, resulting in failure to comprehensively assess, classify, and document restraint use, application and utilization of a restraint for a cognitively and physically impaired resident, lack of informed consent, and the likelihood for knowledge deficiency related to risks, physical discomfort and psychosocial distress utilizing the reasonable person concept. […]