Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Lenawee Medical Care Facility during CMS and state inspections, most recent first.
The facility did not maintain required documentation showing that all paid feeding assistants had successfully completed a State-approved training course. Review of facility records showed 12 staff functioning as paid feeding assistants and 9 residents approved for the paid feeding assistant program, but the DON reported that documentation of completed training could only be found for 6 staff. The DON stated that a Life Enrichment Coordinator and several Dining Room Assistants had completed the training and assisted with feeding, yet the facility was unable to locate records verifying their training completion.
Failure to Assess Resident for Self-Administration of Medications: A resident with COPD, HF, anxiety, depression, and a BIMS of 15 was observed during med pass with the RN leaving meds and an inhaler at the bedside, not performing hand hygiene, and allowing the resident to use her inhaler on her own without a documented assessment permitting independent self-administration. The RN also did not provide water to rinse and spit after the inhaler, and the DON stated bedside medication administration was not expected unless an assessment allowed it.
Protected resident information was left visible during medication administration when an RN walked into a resident’s room with the med cart computer screen open and a resident list and daily report face up on the cart. The RN also left meds and an inhaler at the bedside, left the room to get a BP machine, and was observed without hand hygiene before giving meds. The DON confirmed the expectation was to close the screen and not leave resident names visible on the cart.
Delayed Significant Change in Status MDS for a resident enrolled in hospice. A resident with MS and moderate cognitive impairment was enrolled in hospice, triggering an SCSA requirement, but the MDS was completed after the required timeframe. The MDS nurse stated the assessment should have been locked earlier, and the record showed the ARD and completion dates did not meet CMS timing requirements.
Failure to implement a restorative ROM program for a resident with left lower extremity impairment and limited mobility. The resident was observed seated in a wheelchair with the legs extended and the left leg bent outward, while PT and OT discharge summaries recommended restorative services including lower extremity strengthening, passive ROM, AAROM, AROM, and restorative ROM. Staff reported a referral had been made, but the resident was not yet on the restorative program because the caseload was too large and the resident was on a waiting list.
Medication administration errors exceeded the allowed rate when an RN failed to perform hand hygiene, left meds and an inhaler at the bedside while leaving the room, did not provide water for rinsing after the resident self-administered a budesonide-formoterol inhaler, and attempted to apply a discontinued Lidoderm patch instead of the active lidocaine cream order. The DON stated meds should not be left at the bedside unless the resident has an assessment allowing self-administration, and the resident had no such assessment in the record.
Failure to perform hand hygiene during medication administration: An RN entered a resident’s room with medications, handed them to the resident, left the meds and inhaler on the over-bed table, returned with a BP machine, and continued care without hand hygiene before or after these actions. The resident had COPD, HF, AKF, anxiety, depression, and SOB, and the DON stated the expectation was for the medication pass nurse to perform hand hygiene before and after passing medications.
A deficiency occurred when the facility failed to thoroughly investigate and report a substantiated incident of sexual abuse between two cognitively impaired residents, both with multiple comorbidities and requiring one-person assistance with ADLs. Video footage and a CNA witness confirmed that a male resident in a wheelchair repeatedly touched a female resident’s breasts near the nurse’s station before being separated by staff. Despite this, the facility did not interview other residents or staff on the unit about the resident’s ongoing inappropriate sexual comments and behaviors, did not provide staff education related to the incident, and moved the alleged perpetrator to another hallway with other vulnerable female residents. The facility also did not notify law enforcement of the witnessed and recorded sexual abuse, with leadership citing the residents’ cognitive impairment as the reason for not calling the police.
A CNA recorded a video of a resident with moderate cognitive impairment in her room without consent while the resident was on the phone, then shared the video via social media. The resident was unaware of being recorded, and the video was further disseminated, violating facility policy and the resident's right to privacy.
A resident with a history of right femur fracture and Multiple Sclerosis, dependent for transfers, was injured when a CNA attempted a transfer alone using a sit-to-stand lift, contrary to the care plan requiring two-person assistance. The resident's leg gave out during the transfer, resulting in a fall and subsequent femur fracture, which was confirmed after ongoing pain and further imaging.
A resident's personal property was misappropriated when a CNA removed and discarded colored pictures from the resident's room without permission, leading to the resident's distress. The facility's investigation confirmed the incident, which was reportedly due to competition between CNAs.
Missing Documentation of State-Approved Training for Paid Feeding Assistants
Penalty
Summary
The facility failed to maintain records of successful completion of a State-approved paid feeding assistant training course for 6 of 12 staff members functioning as paid feeding assistants. Surveyors reviewed facility lists showing 12 staff designated as paid feeding assistants and 9 residents approved for the paid feeding assistant program. During an interview, the DON stated the facility could only locate documentation of completed State-approved training for 6 of the 12 paid feeding assistants. The DON identified specific staff, including the Life Enrichment Coordinator and multiple Dining Room Assistants, who had reportedly completed the paid feeding assistant training and had assisted residents with feeding, but the facility was unable to locate documentation verifying that these individuals had completed the required training. No additional clinical details or medical histories of the 9 residents approved for the paid feeding assistant program were provided in the report, and the deficiency centers on the absence of required training documentation for staff who assisted with feeding.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess one resident, R121, for permission to self-administer medications safely and independently. R121 was admitted with diagnoses including COPD, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. Her most recent MDS showed a BIMS score of 15 out of 15, and she required minimum assistance with showering, personal care, dressing, and putting on footwear, although that section of the assessment was not completed at the time. During a medication pass observation, an RN removed medications from the cart, left the computer screen open with resident information visible, and did not perform hand hygiene before handling and giving medications to R121. The RN left the medications and inhaler on the over-bed table and stepped out of the room to get a blood pressure machine. After returning and obtaining a BP of 151/92, the RN allowed R121 to state that she used her inhaler on her own, then handed her a blood pressure pill without observed hand hygiene before returning to the cart or before giving the medication. The inhaler was Budesonide-Formoterol Fumarate Inhalation Aerosol, ordered for COPD with instructions to rinse the mouth after use, but no water was provided for rinse and spit. R121 stated nurses usually stayed in her room while she took medications and that she could not always take them all at once. Record review did not show an assessment authorizing self-administration, and the DON stated the nurse should not leave medications at the bedside unless there was an assessment permitting self-administration and should provide water to rinse and spit after inhaler use.
Protected Resident Information Left Visible During Medication Administration
Penalty
Summary
The facility failed to protect personal, private, and confidential information for one resident, R121. R121 was admitted with diagnoses including chronic obstructive pulmonary disease, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. The most recent MDS showed a BIMS score of 15 out of 15 and indicated the resident needed minimum assistance with showering, personal care, dressing, and putting on footwear, though that section was not completed at the time referenced in the report. During an observation, an RN was seen pulling medications from the medication cart to administer to R121 and walked into the resident’s room with the medications while leaving the computer screen open with R121’s personal and protected information visible. The screen also showed a list of resident names and a daily report face up on the cart. The RN did not perform hand hygiene before handing medications to the resident, left medications and an inhaler on the over-bed table, left the room to get a blood pressure machine, and later returned to give the blood pressure medication without observed hand hygiene before accessing the cart or after handing the medication to the resident. The DON stated the expectation was to close the computer screen before leaving the medication cart unattended and that the same expectation applied to leaving the resident list face up on the cart.
Delayed Significant Change in Status MDS for Resident Enrolled in Hospice
Penalty
Summary
The facility failed to complete a Significant Change in Status MDS assessment timely for one resident. The resident was admitted and later readmitted to the facility with a diagnosis that included Multiple Sclerosis, and the Significant Change in Status MDS reflected moderate cognitive impairment on the BIMS and that the resident received hospice services. The MDS had an ARD of 2/5/26 and was completed on 2/19/26. Record review showed the resident was admitted to hospice services on 1/30/26, and the MDS nurse reported that the significant change in status occurred on that date when the resident enrolled in hospice. In a follow-up interview, the MDS nurse stated the Significant Change in Status MDS should have been locked by 2/12/26. The CMS LTC Facility Resident Assessment Instrument 3.0 User’s Manual states that an SCSA is required when a terminally ill resident enrolls in hospice, with the ARD within 14 days of the hospice election and the MDS completion date no later than 14 days from the ARD and no later than 14 days after the determination that the criteria were met.
Failure to Implement Restorative ROM Program
Penalty
Summary
The facility failed to implement a restorative maintenance program for one resident who had been admitted with diagnoses including a non-pressure chronic ulcer of the left thigh with necrosis of muscle, a displaced intertrochanteric fracture of the left femur, and a left artificial knee joint. The admission MDS dated 2/1/26 showed the resident scored 8 out of 15 on the BIMS and had lower extremity impairment on one side that interfered with daily functions or placed the resident at risk of injury in the last 7 days. On 3/17/26 and 3/18/26, the resident was observed seated in a wheelchair in the room, watching TV and later minimally self-propelling with the arms. On both observations, the wheelchair footrests were elevated to approximately seat level height, the legs were extended, and the left leg was bent laterally at the knee. Therapy documentation showed the resident was discharged from PT and OT on 2/18/26, with recommendations for restorative services including lower extremity strengthening, passive ROM, active assisted ROM, active ROM, and restorative ROM. In interviews, the Therapy Director and RN reported a referral had been made for restorative services, but the resident was not yet on the restorative program because the caseload was too large and there was a waiting list; staff also stated the facility had two restorative aides plus one as-needed aide and about 25 residents on restorative services at the time.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent when two medication errors were observed during 30 medication administration opportunities for one resident, resulting in a 6.67 percent error rate. The resident involved had diagnoses including COPD, heart failure, acute kidney failure, anxiety, depression, shortness of breath, and pain in both shoulders, and the most recent MDS showed a BIMS score of 15. During observation, an RN did not perform hand hygiene before giving the resident medications, left the medications and inhaler on the over-bed table while leaving the room to obtain a blood pressure machine, and did not provide water for the resident to rinse and spit after self-administering Budesonide-Formoterol inhalation aerosol. During the same medication pass, the RN also pulled a Lidoderm 4% patch to apply to the resident’s shoulders even though the record showed that the patch had been discontinued the prior evening and a new order had been written for Lidocaine 4% external cream instead. The resident stated nurses usually stay in the room during medication administration and that she was not offered water to rinse and spit after using her inhaler. The DON stated the expectation was to verify the medication order, check allergies, and triple-check the medication against the order and resident, and confirmed that if an order was discontinued the nurse should notice it and that medications should not be left at the bedside unless the resident had an assessment allowing self-administration.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was not followed during medication administration for one resident. During observation, the RN pulled medications from the medication cart and went into the resident’s room without performing hand hygiene. The RN handed the resident her medications without hand hygiene, then left the medications and inhaler on the over-bed table while leaving the room to get a blood pressure machine. The RN returned with the BP machine, again without performing hand hygiene, and took the resident’s vital signs with a BP of 151/92. The resident was admitted with diagnoses including COPD, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. The most recent MDS showed a BIMS score of 15 out of 15 and indicated the resident needed minimum assistance with showering, personal care, dressing, and putting on footwear. During interview, the DON stated it was the expectation for the medication pass nurse to perform hand hygiene before and after passing medications.
Failure to Thoroughly Investigate and Report Substantiated Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and appropriately respond to an alleged and substantiated incident of sexual abuse between two cognitively impaired residents. One resident (R2), with CHF, stroke, traumatic brain injury, dysphagia, major depression, hypertension, bipolar disorder, weakness, and unsteady gait, had a BIMS score of 7 indicating moderate to severe cognitive impairment and required one-person assistance with ADLs. Another resident (R3), with CHF, adjustment disorder, vascular dementia without behavioral disturbance, unsteady gait, and gait abnormalities, had a BIMS score of 3 indicating severe cognitive impairment and also required one-person assistance with ADLs. Camera footage and staff observation documented that R3, while in his wheelchair near the nurse’s station, touched R2’s face, rubbed her back, and then repeatedly touched both of R2’s breasts before being separated by a CNA. The facility verified the incident by reviewing the hallway camera footage and obtaining a witness statement from the CNA who intervened, confirming that R3 touched both of R2’s breasts. However, the investigation was limited to these immediate observations and did not include interviews with other residents on the same household regarding R3’s inappropriate behaviors, comments, or touching of female residents. The record also did not show interviews with other staff working on that household about R3’s prior or ongoing inappropriate behaviors or comments toward female residents or staff, despite staff later reporting that R3 was flirty with female residents and staff, made sexually suggestive comments, and had been “a little hands on” with staff. The facility moved R3 from one alert hallway to another where other vulnerable female residents lived, but records showed no evidence of staff education related to this sexual abuse incident, even though this was not the first time R3 had exhibited inappropriate behaviors and comments. The facility did not contact law enforcement regarding the witnessed and video-recorded sexual abuse, with the Nursing Home Administrator stating that police were not called because both residents were cognitively impaired and providing no other explanation. The record review and interviews confirmed that the facility failed to conduct a thorough investigation, failed to interview potentially affected residents and staff, failed to provide education to staff regarding the incident, and failed to report the substantiated sexual abuse to the police as required by regulation.
Resident Privacy Violated by Unauthorized Video Recording
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) recorded a video of a resident in her room without her knowledge or consent. The resident, who had diagnoses including Parkinson's Disease, vascular dementia, and major depressive disorder, was moderately cognitively impaired according to her most recent assessment. The video was taken from behind the resident while she was sitting in her wheelchair, watching television, and talking on the phone. The CNA then turned the camera on herself at the end of the video. The resident was unaware that she had been recorded and, when asked, stated her feelings about being recorded would depend on the circumstances, but she had no knowledge of this specific incident. The video was sent via social media messenger to another CNA, who shared a social media account with a third party, allowing the video to be further disseminated. Facility investigation confirmed that the video was recorded and shared without the resident's awareness, violating the facility's policy prohibiting photography or video recordings on the property and the resident's right to privacy. The CNA involved admitted to recording the video as a form of personal documentation related to workplace allegations, not for any resident care purpose.
Failure to Follow Transfer Care Plan Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent for transfers and had a history of right femur fracture and Multiple Sclerosis, was not transferred according to their care plan. The care plan and Kardex specified that two-person assistance was required for transfers using a sit-to-stand lift. However, a CNA attempted the transfer alone, relying on outdated information from a report sheet that did not reflect the updated care plan requirements. During the transfer, the resident's right leg gave out, and although the wheelchair was locked, it moved backward, causing the resident's legs to slide out and resulting in the resident being lowered to the floor and landing hard on their buttocks. The resident immediately began experiencing significant pain in the right thigh, which persisted and worsened over the following days. Initial x-rays did not reveal a fracture, but ongoing pain and subsequent imaging confirmed a femur fracture with callus formation, necessitating surgical intervention. The incident was further complicated by the resident's continued reports of severe pain during movement and care, as documented in multiple progress notes and medication administration records. The failure to follow the care plan for transfer assistance directly led to the resident being injured during the transfer process.
Misappropriation of Resident's Personal Property
Penalty
Summary
The facility failed to protect the personal property of a resident, leading to feelings of sadness and potential mistrust. The resident, who was cognitively intact, had colored pictures on her wall that were created by a favorite CNA. Another CNA, without the resident's permission, removed and discarded these pictures, which upset the resident. The incident was observed by the resident's family member, who noted a possible competition between the two CNAs as a reason for the removal of the pictures. The facility's investigation, which included reviewing camera footage, confirmed that the CNA entered the resident's room when she was absent and discarded the pictures. The CNA admitted to removing the pictures, claiming they caused the resident distress. The social worker and nursing home administrator were informed, and the incident was reported and substantiated as misappropriation of property.
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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 Adrian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springcreek Rehabilitation And Nursing Center | 0.2 mi | — | 22 | 0 |
| Lynwood Manor Healthcare Center | 1.9 mi | — | 1 | 0 |
| Adrian Bay Rehabilitation And Nursing Center | 2 mi | — | 5 | 0 |
| Otterbein Sunset Village | 20 mi | — | 3 | 0 |
| Lakes Of Sylvania, The | 21 mi | — | 9 | 0 |
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