Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ingham County Medical Care Facility during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to adhere to professional standards for food storage and preparation, with multiple expired and unlabeled items found in the kitchen and rehab cooler. Additionally, food served during meal service was not maintained at safe temperatures, violating the 2017 FDA Food Code.
A facility failed to ensure proper witnessing of a DNR document for a resident with encephalopathy and hemiplegia following a stroke. The resident signed the DNR form, followed by the physician and two witnesses on subsequent days. However, the Social Services Supervisor admitted to signing as a witness without actually observing the signing, indicating a failure to ensure the signing was properly witnessed.
A resident with severe cognitive impairment and a history of inappropriate behavior was involved in multiple incidents of alleged abuse. Despite being reported and investigated, the facility failed to implement effective preventive measures. The care plan for the resident was not consistently enforced, and staff were not adequately informed or trained, leading to repeated incidents.
The facility failed to complete PASARR Level II evaluations for two residents with significant mental health diagnoses, despite indications from Level I screenings. The evaluations were delayed due to the facility's physician not providing the necessary signature, as reported by the Social Services Supervisor.
A resident with pressure ulcers did not receive proper care as the facility failed to ensure the functionality of an air mattress pump, a key intervention in the care plan. The pump was found non-functional on several occasions, and staff were unaware of its status, compromising the resident's wound healing process.
A resident with dementia and depression was not provided with a meaningful activity program, despite their interests in exercise, music, TV, and group activities. Observations showed the resident was often left in their room with no engagement, and records indicated minimal participation in activities. The facility's administration failed to explain the lack of engagement in the resident's preferred activities.
A facility failed to ensure monthly drug regimen reviews by a licensed pharmacist and provider for a resident with multiple diagnoses, including schizophrenia and diabetes. Pharmacy recommendations to adjust medication dosages and conduct evaluations were either not addressed or disagreed with without rationale. The provider did not sign medication review forms within the expected timeframe, leading to deficiencies in medication management.
Expired medications were found in a medication cart and storage rooms, including Thiamin Vitamin B-1, Move+Vision+Bones+Supplement, and Calcium Carbonate. The DON stated that nurses checked medications during the night shift, and the central supply person was supposed to help monitor the carts and rooms but did not.
A facility failed to administer an influenza vaccine to a resident with dementia and heart failure, despite receiving verbal consent from the resident's legal guardian. The resident had not received the vaccine since the previous year, and the facility's Director of Nursing confirmed the absence of a record for the vaccine administration after consent was given.
The facility failed to provide proper transfer/discharge notices for two residents, one cognitively intact and the other with moderate cognitive impairment, during hospital transfers. Despite procedures indicating that notices should be given and documented, neither resident nor their representatives received the required notifications, as confirmed by interviews and record reviews.
The facility failed to provide a written bed hold notification in an understandable language to two residents, leading to potential confusion about the bed hold policy. One resident, who was cognitively intact, did not receive documentation during hospital transfers, while another resident's responsible party was not informed of the policy and was told the resident would not be readmitted due to an outstanding balance.
A facility failed to readmit a resident after hospitalization due to an outstanding balance, despite the resident being medically stable for discharge. The resident, with a history of metabolic encephalopathy, diabetes, and heart failure, remained in the hospital while alternative placement was sought. The facility's refusal was confirmed by both the resident's guardian and the hospital's case manager.
The facility failed to date mark potentially hazardous ready-to-eat foods in two resident refrigerators. Observations revealed undated and expired items, including yogurt, salad dressing, and various other food products. The Dining Services Director was unaware of who was responsible for maintaining the refrigerators, and the facility's food storage guidelines were not adhered to.
A resident with a seizure disorder did not receive three doses of acetazolamide due to the medication being misplaced in the cart. The facility failed to notify the physician of the missed doses, and the issue was discovered by the Unit Manager/LPN after being informed by the resident's family.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen's reach-in cooler, several food items were found with expired use-by dates, including chicken, pureed vegetables, blue cheese dressing, and pureed pasta. Additionally, an unlabeled and undated container of food was discovered. Similar issues were observed in the rehab kitchen, where a cloth hamper was overflowing with soiled rags and aprons, attracting fruit flies. The reach-in cooler in the rehab kitchen contained expired items such as coffee creamer, thickened water, smoothies, barbeque sauce, ketchup, and vanilla pudding. The dry storage area also had expired dry cereal, and the walk-in cooler contained a tray of bedtime snacks and other items past their use-by dates. The Dining Services Manager acknowledged these issues and removed the expired and undated items. Further deficiencies were noted in the temperature control of food items. During a meal service observation, the temperature of a chicken breast on the steam table was found to be 123 degrees Fahrenheit, which was below the required temperature for safe consumption. A subsequent test tray revealed that the chicken breast, potatoes, and green beans were all served at temperatures below the required 135 degrees Fahrenheit, with the milk being slightly above the safe temperature of 41 degrees Fahrenheit. These findings indicate a failure to maintain proper time/temperature control for safety food, as specified by the 2017 FDA Food Code.
Failure to Ensure Proper Witnessing of DNR Document
Penalty
Summary
The facility failed to ensure that witnesses observed the signing of a Do-Not-Resuscitate (DNR) document for a resident. The resident, who had been admitted and readmitted to the facility with diagnoses including encephalopathy and left side hemiplegia and hemiparesis following a stroke, signed the DNR form on March 1, 2024. The physician signed the form on March 5, 2024, and two witnesses signed on March 6, 2024. The Attestation of Witnesses section of the DNR document indicated that the individual appeared to be of sound mind and under no duress, fraud, or undue influence. However, during an interview, the Social Services Supervisor reported that they would sign as a witness if they talked to the person who signed the DNR document, even if they did not actually witness the signing. This indicates a failure to ensure that the signing was properly witnessed as required.
Inadequate Response to Allegations of Abuse
Penalty
Summary
The facility failed to implement appropriate preventive measures and take corrective action for allegations of abuse involving three residents. Resident #33 reported being molested by another resident, #113, during a bingo game. Despite the incident being reported and investigated, the only measure taken was to seat Resident #113 a few tables away during bingo. The facility's response was inadequate as Resident #113, who has a history of sexually inappropriate behavior, was not properly monitored or restricted from interacting with female residents. Resident #113, with severe cognitive impairment and a history of inappropriate behavior, was involved in multiple incidents of alleged abuse. During a bingo game, Resident #113 allegedly touched Resident #33 inappropriately, which was witnessed by an Activity Aide. The aide intervened by seating another aide between the two residents but did not report any further preventive measures. Additionally, Resident #113 was involved in another incident with Resident #9, where inappropriate touching was reported. The facility's investigation revealed that Resident #113 was unable to recall the incident due to cognitive deficits. The facility's care plan for Resident #113, which included interventions to prevent inappropriate behavior, was not effectively implemented. The care plan was updated to include monitoring and redirecting Resident #113 away from female residents, but these measures were not consistently enforced. Staff members, including a Resident Aide, were not adequately informed or trained on the specific interventions required to manage Resident #113's behavior, leading to repeated incidents of abuse.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a Level II determination was completed for two residents, both of whom had significant mental health diagnoses. Resident #83 was admitted with diagnoses including schizoaffective disorder and dementia with psychotic disturbance. Despite being prescribed antipsychotic and antidepressant medications, the resident did not have a Level II evaluation or exemption completed, even though the PASARR Level I Screening indicated the need for further evaluation. Similarly, Resident #104, who was admitted with PTSD, vascular dementia, and severe cognitive impairment, also lacked a Level II evaluation or exemption, despite the PASARR Level I Screening indicating the necessity for it. The deficiency was further highlighted during an interview with the Social Services Supervisor, who reported that the Level II evaluations for both residents were still in progress according to the Community Mental Health Services Program's (CMHSP) website. However, the evaluations had not been completed because the facility's physician had not yet provided their signature, which was necessary for the process to move forward. This oversight resulted in the facility's failure to comply with the required PASARR process for residents with mental disorders or intellectual disabilities.
Failure to Implement Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to implement care planned interventions for a resident with pressure ulcers, leading to a deficiency in wound care management. The resident, who was admitted with a stage four pressure ulcer and an unstageable pressure ulcer, was dependent on two staff members for repositioning and turning in bed. The care plan included the use of an alternating pressure mattress to promote healing. However, observations revealed that the air mattress pump was not functioning on multiple occasions, as indicated by the absence of illuminated lights on the pump. The resident reported that the mattress was sometimes soft and that staff occasionally unplugged the air mattress when moving the bed. Further investigation showed that a Licensed Practical Nurse (LPN) discovered the air mattress pump was off and, upon reconnecting the power cord, the pump turned on. The LPN was unaware of how long the pump had been off. A Registered Nurse (RN) confirmed the purpose of the air mattress was to alleviate pressure, yet the pump was observed to be non-functional again the following day. This lack of consistent functionality of the air mattress pump indicates a failure to adhere to the care plan designed to support the resident's wound healing process.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide a meaningful, diverse, and engaging activity program for a resident diagnosed with dementia and depression, who was admitted with long and short-term memory impairment and severely impaired decision-making skills. Observations over several days revealed the resident was repeatedly left in their room, sitting in a wheelchair against the wall with the television off and no music playing. Despite the resident's activity assessment indicating interests in exercise, music, TV, movies, outdoor activities, and group interactions, there was no evidence of participation in these activities over the past 30 days, except for minimal one-on-one interactions. The activity participation records showed limited engagement, with only a few instances of conversation and TV watching. During an interview, the Nursing Home Administrator and Activity Director acknowledged that activity participation records were being trialed through a new computer program but failed to provide a clear explanation for the lack of engagement in the resident's preferred activities. There was no documentation indicating that the resident had been invited to or refused any activities of interest, highlighting a deficiency in meeting the resident's needs for meaningful engagement.
Failure in Monthly Drug Regimen Review and Provider Response
Penalty
Summary
The facility failed to ensure that drug regimens were reviewed at least once a month by a licensed pharmacist and provider for one of the residents reviewed for medication management and monitoring. The resident, who was initially admitted to the facility with diagnoses including anxiety, schizophrenia, diabetes mellitus, and coronary artery disease, had several instances where pharmacy recommendations were not appropriately addressed by the provider. For example, recommendations to adjust the dosage of Eliquis and to conduct an abnormal involuntary movement evaluation were either disagreed with without rationale or not responded to at all. Additionally, there were instances where the provider did not sign the medication review forms within the expected timeframe, and some recommendations, such as discontinuing certain medications or adjusting dosages, were left unaddressed. The Director of Nursing (DON) acknowledged that the Nurse Practitioner responsible for these oversights had been terminated and noted that the expectation was for providers to respond to pharmacy recommendations within 7 days, or 30 days at the latest. However, this expectation was not met, leading to the deficiency in medication management for the resident.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to properly dispose of expired medications, as observed in one of four medication carts and one of three medication storage rooms. During an observation, a bottle of Thiamin Vitamin B-1 100mg with an expiration date of March 2024 was found on the Blue Cart. Additionally, in the Blue Medication Room, a bottle of Move+Vision+Bones+Supplement expired in April 2024 was observed. Furthermore, in the [NAME] Ridge Medication Room, two bottles of Calcium Carbonate 500mg with an expiration date of April 2024 were found. During an interview, the Director of Nursing (DON) B stated that nurses were responsible for checking medications during the night shift. DON B also mentioned that the central supply person was supposed to assist in monitoring the medication carts and rooms, but they did not check the carts and rooms as expected.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to administer an influenza immunization to Resident #46, despite having received consent from the resident's legal guardian. Resident #46, who was admitted with diagnoses including dementia and heart failure, had moderately impaired cognitive skills and required a legal guardian for decision-making. The facility attempted to obtain consent for the influenza vaccine by leaving messages and sending a letter to the guardian, but received no reply initially. After the resident was hospitalized and returned to the facility, verbal consent for the influenza immunization was given by the guardian on 10/25/23. However, the facility did not administer the vaccine, and the last recorded influenza immunization for the resident was on 10/13/22. The Director of Nursing confirmed that there was no record of the vaccine being administered after consent was obtained.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to meet transfer and discharge documentation requirements for two residents, resulting in the potential for these residents and/or their representatives not obtaining their due rights. Resident 39, who was cognitively intact, was transferred to the hospital twice without receiving a transfer/discharge notice. The nursing home administrator stated that the admissions office was responsible for the bed hold policy and transfer notices, while a licensed practical nurse indicated that a transfer/discharge/bed hold packet should be given to the resident or family and scanned into the chart. However, there was no documentation of the notice being provided to Resident 39. Similarly, Resident 19, who had moderate cognitive impairment, was transferred to the hospital without a transfer/discharge notice being provided to the responsible party. Although the facility later provided a Transfer Notice Form and claimed that the notice was mailed to the resident's guardian, the guardian reported not receiving it. These deficiencies highlight a failure in the facility's process for ensuring that residents and their representatives are properly notified of transfers or discharges, as required by regulations.
Failure to Provide Bed Hold Notification in Understandable Language
Penalty
Summary
The facility failed to provide a written bed hold notification to two residents, R39 and R19, in a language that was understandable, which resulted in a potential lack of understanding of the bed hold policy. For Resident 39, who was cognitively intact and required maximum assistance with personal care, there was no documentation of a transfer/discharge/bed hold notice being provided during two hospital transfers. Interviews with the Nursing Home Administrator and a Licensed Practical Nurse revealed that the responsibility for providing these notices was part of the admissions office role, and a template was available but not documented in the resident's chart. For Resident 19, who had moderate cognitive impairment, there was no documentation of a bed hold notice being provided to the responsible party upon transfer to the hospital. The Admissions Director reported that the facility called the responsible party within 24 hours of the resident leaving, but the Guardian stated they were not notified of the bed hold policy. Instead, they were informed that the facility would not readmit the resident due to an outstanding balance. A Social Services Supervisor confirmed a conversation with the Guardian about the non-readmission due to payment issues.
Facility Fails to Readmit Resident Due to Payment Issues
Penalty
Summary
The facility failed to permit timely readmission for a resident after hospitalization, which led to a deficiency. The resident, who had a history of metabolic encephalopathy, diabetes, and heart failure, was initially admitted to the facility and later transferred to the hospital due to being unresponsive. The hospital determined the resident was stable for discharge, but the facility declined readmission due to an outstanding balance, as reported by the resident's guardian and confirmed by the facility's Social Services Supervisor. The hospital's case manager also reported that the facility's admissions department refused the resident's return, citing payment issues. Consequently, the resident remained in the hospital while alternative placement was sought, despite being medically stable for discharge. This situation persisted until the resident was eventually discharged back to the facility, highlighting the facility's failure to adhere to regulations regarding resident readmission after hospitalization.
Failure to Date Mark Ready-to-Eat Foods in Resident Refrigerators
Penalty
Summary
The facility failed to date mark all potentially hazardous ready-to-eat food products in two of the three resident refrigerators reviewed. During an observation of the rehab unit resident refrigerator, several items were found undated, including a bowl of unknown food, a squirt bottle of salad dressing, a bowl of peas, a cup of milk, a container of salad, and a container of thickened orange juice. Additionally, expired items such as Chobani blueberry Greek yogurt and a container of roasted turkey BLT from the facility's bistro were found. The Dining Services Director (DSD) was unaware of who was responsible for maintaining the resident refrigerators. In the memory care unit resident refrigerator, similar issues were observed, with several undated items including seven bowls of food, an opened container of thick and easy, chocolate syrup, two half gallons of chocolate milk, two cups of orange juice, and a mighty shake. An opened med pass fortified nutritional shake was dated but not within the acceptable timeframe. The DSD confirmed that the foods were not labeled and/or expired. The facility's Dining Services Food Storage Chart, which was posted on the front of the rehab unit refrigerator, outlined specific storage timelines for various food items, but these guidelines were not followed, leading to the deficiency.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of acetazolamide, a medication prescribed for seizure disorder. The resident, who was diagnosed with seizure disorder and muscular dystrophy, did not receive the prescribed doses of acetazolamide on two occasions. The medication was not administered in the afternoon and evening on one day and the following morning. Nursing notes indicated that the medication was not available, and there was no documentation that the physician had been notified of the missed doses. The incident report revealed that the medication was actually present in the medication cart but had been placed backward and in the wrong slot, leading to the oversight. The Unit Manager/LPN became aware of the missed doses through the resident's family and subsequently found the misplaced medication in the cart. Despite attempts to contact the responsible nurses, no explanation was provided as to why the physician was not informed of the missed doses.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Okemos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Willows At Okemos | 2 mi | — | 7 | 0 |
| Medilodge Of Okemos | 2.8 mi | — | 0 | 0 |
| Medilodge Of Campus Area | 3.2 mi | — | 1 | 0 |
| Burcham Hills Retirement Center | 3.9 mi | — | 4 | 0 |
| Medilodge Of East Lansing | 5 mi | — | 26 | 0 |
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