Lenawee Medical Care Facility

In the surveyor’s words

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

• Actual harm, isolatedF600May 14, 2026

  This Citation Pertains to Intake 2997912.Based on observations/interviews and record review, the facility failed to protect the resident's right to be free from of physical and mental abuse perpetrated by staff for one resident (Resident #2) of three reviewed. Resulting in R2 being abused by staff. Findings include:Review of Resident #2's (R2) clinical record, including the Minimum Data Set, dated [DATE] revealed R2 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia, heart failure and adult failure to thrive. R2 scored 99 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and received hospice care. […]

• Actual harm, isolatedF604May 14, 2026

  This Citation Pertains to Intake 2997912.Based on observation, interview and record review the facility failed to ensure one resident (resident #2) was free from physical restraints, resulting in anger frustration. Findings include:Review of Resident #2's (R2) clinical record, including the Minimum Data Set, dated [DATE] revealed R2 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia, heart failure and adult failure to thrive. R2 scored 99 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and received hospice care. Review of R2's behavior care plan that was in place on 4/18/26, dated 01/02/26 identified R2 was resistant to care and could be combative with caregivers. […]

• Actual harm, isolatedF689Jun 25, 2025

  This citation pertains to intake MI00153332. Based on observation, interview and record review, the facility failed to ensure a transfer was performed according to the plan of care for one (R3) of three reviewed, resulting in R3 being lowered to the floor and sustaining a fracture. Findings include: Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included fracture of unspecified part of neck of right femur and Multiple Sclerosis. […]

• Actual harm, isolatedF678Nov 16, 2023

  Based on interview and record review, the facility failed to ensure staff had proper certification for Cardiopulmonary Resuscitation (CPR- medical interventions used to restore circulatory and/or respiratory function that has ceased), including 2 (Nurses K and I) of 6 reviewed for CPR certification, resulting in the likelihood of residents not receiving adequate life sustaining treatments in the event of a sudden change in condition, potentially affecting all residents choosing to receive CPR. Review of the medical record reflected Resident #111 (R111) was admitted to the facility on [DATE], with diagnoses that included essential hypertension, Type 2 diabetes with diabetic neuropathy, sleep apnea, and acute respiratory failure. […]

• Actual harm, isolatedF600Oct 19, 2023

  This citation pertains to intakes MI00136626 and MI00140194. Based on observation, interview, and record review the facility failed to protect the residents' right to be free from sexual abuse by a resident for two residents (Resident #6 and Resident #3) of six reviewed, resulting in Resident #6 being sexually abused by Resident #5 which caused increased tearfulness, anxiety, and emotional distress and Resident #3 being sexually abused by Resident #4. Findings include: Resident #5 (R5) and Resident #6 (R6) Review of the medical record revealed R5 admitted to the facility on [DATE] with diagnoses that included diabetes, anxiety disorder, and major depressive disorder. […]