Newaygo Co Medical Care Facility

In the surveyor’s words

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

• Immediate jeopardy, patternF686Mar 16, 2022

  This citation pertains to intake: MI 682 Based on observation, interview and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development of avoidable pressure ulcers, 2.) accurately stage resident pressure ulcers, and 3.) promptly identify and provide necessary treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in the development of an unstageable pressure ulcer and likely [CONDITION(S)] for R32. […]

• No harm, potential for more than minimal, patternF628Jun 3, 2026

  Based on interview and record review, the facility failed to notify the resident or the resident's responsible party in writing of the reason for hospital transfers and/or the facility's bed hold policy for 2 of 3 residents (R43 and R58) reviewed for hospitalizations. Findings include: Resident #43 (R43) Review of R43's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and congestive heart failure (CHF). Review of R43's MDS assessment, dated 5/13/26, revealed a BIMS score of 11, indicative of moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF880Mar 16, 2022

  Based on observation, interview, and record review, the facility failed to implement appropriate infection control procedures during the medication pass observation for 1 of 5 residents observed (R151), potentially affecting 28 facility residents, resulting in the potential for cross-contamination and the spread of illness and/or disease. Findings include: During an observation on 03/15/22 at 7:35 AM, Licensed Practical Nurse (LPN) S handled and emptied R151's urinal with bare hands. LPN S then put on gloves (without washing and/or cleansing her hands) and checked R151's blood sugar. […]

• No harm, potential for more than minimal, patternF559Apr 15, 2021

  This citation pertains to intake M 6413 Based on interview and record review, the facility failed to provide written notices to residents and their Guardians/Power of Attorneys (POA) to inform them of a room changes affecting all 62 residents who reside at the facility. Findings include: Resident #1 Review of a Face Sheet revealed Resident #1 is a [AGE] year old male originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In in an interview on 4/13/21 at 4:36 p.m., the Complainant I reported Resident #1 was transferred to another room on another unit in December of 2020 and the family/POA was notified via phone and not given the right to refuse the transfer. […]

• No harm, potential for more than minimal, isolatedF689Jun 3, 2026

  Based on observation, interview, and record review, the facility failed to update and implement care plan interventions for 2 residents (R2 and R6) of 3 residents reviewed for accidents and falls. Findings: R2Review of an admission Record revealed R2 initially admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's disease, dementia, delusional disorders, and hallucinations. Review of a current risk for falls Care Plan intervention for R2, initiated 12/12/2024, directed staff that R2 required a DPM mattress (a specialized mattress with edges or bolsters) to help define edges of R2's bed. […]