Maples Benzie County Medical Care

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 17, 2025

  This citation pertains to Facility Reported Incident (FRI) 2611699.Based on observation, interview, and record review, the facility failed to identify and mitigate environmental hazards, ensure the appropriate use of assistive devices, and implement care planned interventions resulting in falls for three Residents (#24, #25, #26) of three residents reviewed for accident hazards and supervision. This deficient practice resulted in actual harm when Resident #24 sustained multiple lower leg fractures requiring surgical intervention. Findings include:Resident #24 (R24)Review of R24's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/4/23 with diagnoses including vascular dementia, major depressive disorder, and personality disorder. […]

• Actual harm, isolatedF740Mar 30, 2023

  This citation pertains to intake MI00135277. Based on interview and record review, the facility failed to provide appropriate behavioral health services for the expression of suicidal ideation for one Resident (#202) of three Residents reviewed for behavioral health. This deficient practice resulted in actual harm when Resident #202 intentionally overdosed on ibuprofen, resulting in the Resident's hospitalization with subsequent unresponsiveness requiring fluid resuscitation. Findings include: Resident #202 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF600Feb 10, 2023

  This citation pertains to intake MI00133945. Based on interview and record review, the facility failed to protect Resident (#100's) right to be free from neglect when the facility failed to ensure staff competency in following resident care plans and in the use of a mechanical lift during transfers. This deficient practice resulted in actual harm when Resident #100 sustained a fractured right femur, subsequent surgical repair and hospitalization . Findings include: A review of Resident #100's Minimum Data Set (MDS) assessment, dated [DATE], revealed she was admitted to the facility on [DATE] and had diagnoses including dementia, stroke, hearing loss and reduced mobility. […]

• Actual harm, isolatedF689Feb 10, 2023

  This citation pertains to intake MI00133945. Based on interview and record review, the facility failed to ensure appropriate assistance with bed mobility according to the resident care plan for one Resident (#102) of three residents reviewed for accidents. This deficient practice resulted in actual harm when Resident #102 fell from bed and sustained a head laceration requiring emergent transfer to the emergency department and sutures. Findings include: A review of Resident #102's Minimum Data Set (MDS) assessment, dated 12/08/2022, revealed the Resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, muscle weakness and chronic pain. Resident #102 had severe, cognitive impairment. […]

• Actual harm, isolatedF689Dec 1, 2022

  This citation has 2 deficient practice statements (DPS) and pertains to intakes # MI00130986, #MI00132283 and #MI00125389. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to ensure thorough fall investigations were completed, interventions were in place, and new interventions were initiated to prevent falls for three Residents (#56,#62, and #66) out of six Residents reviewed for falls. This deficient practice resulted in repeated falls and a fall with fracture for Resident #62. Findings include: Resident #62 On 11/28/22 at 11:33 p.m., Resident #62 (R62) was observed up in her wheelchair near the door of her room in the hallway. R62 was attempting to self propel herself into her room. […]