Tuscola County Medical Care Facility

In the surveyor’s words

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

• Actual harm, isolatedF686Oct 27, 2023

  Based on observation, interview and record review, the facility failed to prevent development and worsening of pressure ulcers for two residents (Resident #24, Resident #37), resulting in the worsening of a skin injury for Resident #24 and a facility-acquired Stage III pressure ulcer for Resident #37. Findings include: Record review of facility 'Skin Care' policy dated 11/8/2022 revealed a head-to-toe skin assessment is completed and documented on all residents upon admission by a licensed nurse and/or registered nurse, and weekly skin assessment thereafter by licensed or registered nurse that is documented in EMR. Skin Risk assessment to be completed on admission, weekly for 4 weeks then quarterly with MDS schedule and as needed. […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2025

  Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings Include:On 12/9/25 at 10:15 AM, an initial tour of the kitchen was conducted with Dietary Manager (DM) C. The following observations were made: -A drain from the walk-in freezer drained into a hole in the floor. The tube was lower than the floor. -A drain that the DM reported she thought it was for the ice machine, was observed going into a cut out from the floor drain area and did not have an air gap. The drainpipe was below the level of the floor. […]

• No harm, potential for more than minimal, widespreadF921Dec 12, 2025

  Based on observation and interview, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination of the water supply, affecting all residents. Findings include: On 12/11/2025 at approximately 12:41pm-1:24pm during the environmental tour with the Life Safety Officer B, observed a hose attached to a spigot without a backflow preventer at the cold water line located in the boiler room. On 12/11/2025 at approximately 12:41pm-1:24pm observed the water softener drain line sitting directly inside a drain. On 12/11/2025 at approximately 12:41pm-1:24pm observed a utility sink with a chemical feed downstream of an atmospheric vacuum breaker located in the housekeeping closets in Rooms 278, 206, 136, and 178. […]

• No harm, potential for more than minimal, widespreadF880Oct 17, 2024

  Based on observation, interview and record review, the facility 1) Failed to ensure analyzed observational data of personal cares with a continued spread of a Multi-Drug Resistant Organism (MDRO), 2) Failed to ensure proper Personal Protection Equipment (PPE) use, 3) Failed to ensure proper hand hygiene, 4) Failed to ensure proper wound care, 5) Failed to ensure proper perineal (peri) care for two residents (Resident #40, Resident $45) of two residents reviewed for peri-care and 6) Failed to prevent a wound infection for one resident (Resident #45) of three residents reviewed for wound care, resulting in the continued in-house spread of Proteus Mirabilis infections, staff not following enhanced barrier precautions and providing clean cares with the likelihood of the further spread of… […]

• No harm, potential for more than minimal, patternF550Dec 12, 2025

  Based on observation, interview and record review, the facility failed to ensure that residents' rights were being met by 1) Ensuring that call lights were within reach or easily accessible to residents and/or 2) Ensuring that call lights were responded to in a timely manner for four residents (R11, R74, R78 and R121) of four residents sampled for accommodation of needs and also a Confidential Group of Residents. Findings include:Resident #11 (R11): On 12/11/25 at 12:32 PM, an observation was made of Resident 11 sitting up in his wheelchair, propelling himself in his room. An observation was made of the Resident's call light positioned on the floor underneath the bed. The call light hung from the wall and the bed was positioned up against the wall. […]