Schoolcraft Medical Care Facility

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 8, 2025

  This deficiency pertains to Facility Reported Incident (FRI) 2631248Based on observation, interview, and record review, the facility failed to implement interventions and physician recommendations/orders to prevent one Resident (#1) with a known history of elopement of three residents reviewed for elopement from eloping from the facility. This deficient practice resulted in an immediate jeopardy when Resident #1 eloped from the facility and was found 1.2 miles away and was missing for approximately 2 hours, resulting in the likelihood of series injury, harm or death.Findings include:The Immediate Jeopardy began at 12:16 p.m. on 9/28/25 when R1 eloped from the facility undetected and was reported by a facility staff member to be located at a fast-food restaurant, 1.2 miles away at 2:10 pm. […]

• Immediate jeopardy, isolatedF692Nov 17, 2022

  Based on interview and record review, the facility failed to ensure that a tube feeding dependent resident (R14) received nutrition and hydration to meet her estimated needs. This deficient practice resulted in an immediate jeopardy when: 1) R14's tube feeding was discontinued for 33 days, 21 days of which she received only a supplement (providing only 200 calories and 30 grams of protein) and the remaining 12 days she received no nutrition; 2) R14 continued to receive 1350 mL (mililiters) of free water flushes for the first 11 of the 33 days, but the remaining 22 days she received only 600 mL of free water; 3) R14 was restarted on a tube feeding regimen on [DATE] at 7:00 p.m., and at approximately 11:00 pm (4 hours later) she was found unresponsive and was sent to the emergency room (ER);… […]

• Actual harm, isolatedF880Jan 9, 2025

  Based on observation, interview, and record review, the facility failed to implement a comprehensive infection control program to mitigate the spread of Norovirus during an outbreak by failure to: 1. Implement effective disinfection of the facility. 2. Perform outbreak surveillance to track and mitigate the spread of Norovirus. 3. Adhere to Hand Hygiene Infection Control Principles. This deficient practice resulted in a sustained outbreak affecting 18 Residents out of a total facility census of 63 residents who contracted Norovirus. Residents (R26 and R44) were hospitalized from the outbreak. […]

• Actual harm, isolatedF684Feb 14, 2024

  Based on interview and record review, the facility failed to provide comprehensive diabetic management for one Resident (R60) of one resident reviewed for diabetic care. This deficient practice resulted in harm when R60 was hospitalized in the intensive care unit (ICU). Finding include: On 10/4/23, R60 was hospitalized with severe hyperglycemia (high blood glucose levels) and encephalopathy (brain dysfunction that can appear as confusion, memory loss personality changes and/or coma) due to hyperosmolar hyperglycemic state [HHS] (a metabolic complication of diabetes mellitus characterized by severe hyperglycemia, extreme dehydration, and altered consciousness.) Review of R60's Minimum Data Set (MDS) admission assessment, dated 6/14/23, revealed R60 was admitted to the facility on [DATE],… […]

• Actual harm, isolatedF578Nov 17, 2022

  Based on interview and record review, the facility failed to ensure that code status and advanced directives were developed with the appropriate Resident Advocate and were reviewed periodically for appropriateness for one Resident (#14) out of five reviewed for advanced directives. This deficient practice resulted in no documentation of life-sustaining treatment wishes and an expired guardian making life-sustaining treatment decisions. Findings include: A review of R14's medical record revealed she admitted to the facility on [DATE] with diagnoses including cerebral palsy, epilepsy, profound intellectual difficulties, and GERD (gastro-esophageal reflux disease). […]