Macomb Post Acute Care Center

In the surveyor’s words

From the most serious findings on record at Macomb Post Acute Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 10, 2026

  Based on interview, observation, and record review, the facility failed to provide adequate supervision and prevent a cognitively impaired resident with identified exit seeking behaviors and high risk for elopement from exiting the facility, through alarmed doors and failed to identify the resident's elopement. The resident exited the facility unsupervised and wandered approximately 0.4 miles down a main street which has continuous traffic to the hospital and multiple medical complexes. The police were notified by a community member and upon arrival at 6:43 PM the resident was standing on the corner waving down traffic for help. […]

• Immediate jeopardy, isolatedF689Nov 10, 2022

  Based on observation, interview, and record review the facility failed to inform a supervisor prior to transporting a resident in the facility van; failed to educate staff members on safely securing a resident in the facility van and procedure to follow in case of a fall/emergency while in the facility van; failed to secure a resident with a lap belt during transport in the facility van; failed to ensure a resident was assessed by a licensed nurse prior to moving resident; and failed to perform regular maintenance checks of the wheelchair securement system. These failures resulted in V4 (CNA-Certified Nursing Assistant) improperly utilizing facility van to transport R1 to the local parade on 10/22/22. Upon return, V4 hit a bump that caused R1 to 'fly' up in her wheelchair. […]

• Actual harm, isolatedF677Jul 25, 2026

  Based on Observation, Interview and Record Review, the facility failed to ensure a resident with known bowel incontinence was provided dignified incontinence care for one of four residents (R1) reviewed for incontinence care assistance in the sample of seven. This failure resulted in R1 experiencing mental anguish and feeling embarrassed and ashamed of the lack of control of R1 bowels and the need for daily assistance with hygiene. Findings include:The facility's Dignity policy, dated 8/2019, documents Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. […]

• Actual harm, isolatedF697Oct 23, 2024

  Based on observation, interview and record review the facility failed to assess, document and provide pain management for one resident (R2) of three residents reviewed for change in condition. This failure resulted in no pain management provided for 7 hours after R2 fell and sustained a left hip fracture Findings include: Facility Policy/Pain Management and assessment dated [DATE] documents: Evaluation and Assessment: Comprehensive pain assessment tool will be completed upon admission, transfer or onset of new pain which includes: Quality of pain (e.g. burning, aching, numbness) Pain intensity (numeric, visual analog scale, or nonverbal behavior, changes in function observation) Changes in mood state (e.g. […]

• Actual harm, isolatedF689Dec 23, 2023

  Based on observation, interview and record review the facility failed to establish appropriate fall interventions for one cognitively impaired resident (R2) and failed to prevent falls with injury for two of three residents (R1 and R2) reviewed for fall with injuries in a sample of three. These failures resulted in R1 requiring hospitalization , sustaining scalp lacerations and a cervical fracture, and subsequently resulting in R1's death, and R2 requiring hospitalization and sustaining a scalp laceration. […]