Oceana County Medical Care Facility

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 15, 2026

  This citation pertains to intake #: 2996367Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (Resident #2) out of 3 residents reviewed for quality of care resulting in a delay in surgical intervention.Findings:Resident #2 (R2)Review of an admission Record revealed R2 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: severe cervical spinal stenosis (spinal canal narrowing in the neck).Review of R2's hospital After Visit Summary dated 3/4/26 revealed, Please contact (name omitted), neurosurgery, to arrange outpatient follow up of the abnormal cervical spine MRI which does show some pressure on the spinal cord. […]

• Actual harm, isolatedF689May 25, 2022

  This citation has 2 DPS statements. DPS statement #1 is linked to intake # MI 288. DPS statement #1 Based on interview and record review, the facility failed to prevent multiple falls and serious injury for one resident (Resident #326), out of 6 residents reviewed for falls, resulting in an injured right shoulder, lacerations to the lip and head requiring sutures, and fractures of 4 cervical (neck) bones, including the first and second neck bones. Findings: Resident #326 (R326) Review of an Admission Record revealed R326 was an [AGE] years old male, originally admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's, brain cancer, agitation, [CONDITION(S)], and anxiety disorder. […]

• No harm, potential for more than minimal, widespreadF923Aug 7, 2024

  Based on observation and interview, the facility failed to maintain ventilation, resulting in odors and uncirculated air, affecting all residents in the AU Unit and residents living in the 200 Hallways. Findings include: During an observation of the AU Unit on 8/5/24 at approximately 11:00 AM, the air on the halls and in the resident rooms felt muggy, humid and stagnant. During the observation, some of the resident rooms were noted to have lingering bathroom odors. During a family interview on 8/5/24 at 11:11 AM, resident's room was noted to be stagnant and hot. R50's daughter revealed, this room is always this way, we dress for it. On 8/7/24 between 10:58 AM to approximately 11:25 AM, the following AU resident restrooms (103, 109, 117, 127, 131 and 135) were tested using a tissue. […]

• No harm, potential for more than minimal, patternF684Dec 18, 2025

  This citation pertains to intake # 2685659Based on interview and record review, the facility failed to 1.) ensure medications were administered in accordance with physician orders and 2.) accurately document the administration of medications for 6 out of 7 residents (Resident #1, #3, #4, #5, #7, and #8), reviewed for the provision of nursing services during medication administration.Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: history of kidney transplant.Review of R1's Order Summary revealed:11/6/25-11/26-25 Tacrolimus ER Oral Tablet Extended Release 24 Hour Give 2 mg by mouth one time a day (anti-rejection medication).11/27/25-discharge Tacrolimus ER Oral Tablet… […]

• No harm, potential for more than minimal, patternF758Jun 29, 2023

  Based on interview and record review, the facility failed to address a psychotropic medication that was ordered on an as needed (PRN) basis for 1 (Resident #33), resulting in the potential for unnecessary medication. Findings include: Resident #33 (R33) Review of a Face sheet revealed R33 admitted to the facility on [DATE] with pertinent diagnoses of anxiety, congestive heart failure, and non-pressure chronic ulcers in bilateral lower limbs. Review of the Medication Administration/Physician orders for R33 revealed on 4/20/23 an order for Ativan (Lorazepam) 0.5 mg (milligrams) to be given every 8 hours as needed for anxiety and discontinued on 6/26/23. The Ativan was not given every day. […]