McLaren Lapeer Region

In the surveyor’s words

From the most serious findings on record at McLaren Lapeer Region, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 14, 2022

  Based on observation, interview and record review, the facility 1) Failed to provide a safe environment to prevent falls resulting in serious injury; 2) Failed to perform Neurological Assessment post-fall; 3) Failed to complete Incident/Accident reports post fall, and 4) Failed to operationalize facility's Falls Policy for 2 residents (Resident #4 and #111) of 2 residents reviewed for falls, resulting in a forehead contusion with bruising, and rib fractures, requiring hospitalization , pain and suffering for Resident #111, leading to the likelihood to not recognize serious changes in Level of Consciousness (LOC) or other Neurological changes post falls and prevent further falls with serious injuries. […]

• No harm, potential for more than minimal, widespreadF868Sep 9, 2024

  Based on interview and record review the facility failed to ensure that the Quality Assessment and Process Improvement (QAPI) meetings were held quarterly, resulting in the lack of identification of concerns in the facility or corrective action being provided and no monitoring of issues, potentially affecting all residents living in the facility. Findings Include: FACILITY QAPI and QAA On 9/09/2024 at 3:54 PM, the Director of Nursing/DON was interviewed about the facility Quality Assurance Process Improvement/ QAPI program. When asked how often the QAPI committee met, the DON said the committee was supposed to meet quarterly and showed 2 meeting sign in sheets for a QAPI meeting in May 2024 and June 2024. […]

• No harm, potential for more than minimal, widespreadF812Apr 14, 2022

  Based on observation, interview, and record review, the facility failed to 1] Maintain sanitary conditions in the kitchen, 2] Label and store food in refrigerators, freezers and coolers properly, 3] Discard and dispose expired food, 4] Ensure that food preparation/serving equipment was stored clean and dry, resulting in the potential for cross-contamination of food, spoilage and foodbourne illness, to all residents that consume food and beverages from the kitchen, in a census of 13 residents. […]

• No harm, potential for more than minimal, patternF812Sep 4, 2025

  Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include:On 09/02/2025 at 9:35AM during the initial kitchen tour with the Certified Dietary Manager B, observed three separate spray nozzles downstream of atmospheric vacuum breakers located at the dishwasher station. On 09/02/2025 at 11:30am during lunch observation, observed Dietary Staff C reach in her pocket for a pen with gloves on, then proceed to don an additional pair of gloves without washing hands. […]

• No harm, potential for more than minimal, patternF700Sep 9, 2024

  This Citation pertains to Intake Number MI00141690. Based on observation, interview and record review, the facility failed to perform assessments and perform ongoing monitoring of all bed rails to identify potential areas of entrapment for all facility residents including the following residents: #'65, #70, #115, #116, and #120, resulting in the potential for zones of entrapment to remain unidentified, posing a risk to all 15 residents. Findings Include: Resident #65: A record review of the medical record, indicated Resident #65 was admitted to the facility on [DATE] with diagnoses: history of falls with left knee fracture, arthritis, neck pain, hypertension, atrial fibrillation and macular degeneration. […]