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 Tuscola County Medical Care Facility during CMS and state inspections, most recent first.
The facility failed to implement effective infection control practices, leading to the spread of a Multi-Drug Resistant Organism (MDRO) among residents. Staff did not adhere to proper hand hygiene and PPE protocols, contributing to infections. The infection control nurse acknowledged the issue but did not provide adequate staff education or corrective actions. Specific residents were affected, including one with a wound infection and another with multiple UTIs, highlighting the facility's insufficient infection control measures.
The facility failed to include Code Status preferences in the care plans of five residents, despite having documented preferences against or for certain medical interventions. This omission was identified during a review of the facility's care planning process, which requires comprehensive care plans to be completed within seven days of the Admission MDS assessment. The Social Services Director confirmed that the residents' code status was not care planned, highlighting a systemic issue.
The facility failed to follow its policy for indwelling catheter use, affecting multiple residents. Observations showed catheter bags improperly positioned, with dignity bags touching the floor, and discrepancies in catheter size documentation. Care plans lacked updates for proper catheter care, contributing to recurrent UTIs. Physician orders often did not specify catheter sizes, and infection control protocols were not consistently followed.
The facility was found to have expired medications and medical supplies in two medication rooms, including expired protein supplements, aspirin, and Prevacid for a resident. Vaccines were improperly stored with other medications, and temperature monitoring was insufficient, only being recorded once daily. The facility's policy requires proper storage and monitoring of expiration dates, which was not followed.
Two residents in a dementia care unit experienced a lack of dignified and respectful care. One resident expressed back pain without acknowledgment from staff, despite having a care plan for pain management. Another resident, appearing confused, requested to lay down but was initially ignored by CNAs. The facility's policy on resident rights was not upheld, leading to a deficiency.
A resident with a history of falls and multiple medical conditions suffered repeated skin tears and bruising due to inadequate supervision and safety measures. Despite wearing protective arm sleeves, the resident continued to experience injuries, some during transfers with a mechanical lift. The facility's policies did not adequately address the investigation of these injuries, contributing to the ongoing issue.
A facility failed to maintain the prescribed head of bed (HOB) elevation for a resident with a feeding tube, as observed during a survey. The resident, with diagnoses including dysphagia and pneumonitis, required the HOB to be elevated to 30 degrees during and after feeding. However, the HOB was found at only 19 degrees, and the yellow markings meant to guide proper elevation were missing. Nurse M was unsure about the correct alignment, leading to a deficiency in care.
A resident with COPD was observed receiving oxygen at 3 LPM, contrary to the Kardex and care plan specifying 2 LPM. Staff interviews revealed inconsistencies in managing and communicating oxygen flow rates. The facility's policy requires adherence to physician orders and monitoring oxygen saturation, which was not followed.
The facility failed to implement a yearly QAPI Plan specific to its resident population, affecting 127 residents. The Administrator admitted that the QAPI committee did not meet attendee requirements, as the Medical Director/Physician was absent from a meeting, and was unable to provide original attendance documents. Additionally, the Administrator could not clearly articulate the processes for identifying improvement areas and was uncertain about the completion of a performance improvement project (PIP).
Inadequate Infection Control Practices Lead to MDRO Spread
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, resulting in the continued spread of a Multi-Drug Resistant Organism (MDRO), Proteus Mirabilis, among residents. Observations revealed that staff did not adhere to proper hand hygiene and personal protective equipment (PPE) protocols. For instance, a Certified Nursing Assistant (CNA) was observed performing perineal care on a resident without changing gloves after touching multiple surfaces, and a nurse was seen conducting wound care without proper hand hygiene between glove changes. These lapses in infection control practices contributed to the spread of infections within the facility. The facility's infection control nurse acknowledged the presence of MDRO infections but failed to provide adequate staff education and reeducation on infection control practices. Despite conducting hand hygiene and PPE audits, there was no evidence of corrective actions or staff education to address the identified failures. The infection control nurse also relied on educational games rather than direct observation and reeducation of staff performing actual resident care, which may have contributed to the ongoing spread of infections. Specific residents were affected by these deficiencies, including a resident with a wound infection caused by Proteus Mirabilis and another resident with a history of multiple urinary tract infections. The facility's infection control measures were insufficient to prevent the transmission of infections, as evidenced by the presence of contaminated surfaces and improper handling of urinary catheters. The lack of effective infection control practices and oversight led to the continued risk of infection spread among residents.
Failure to Include Code Status in Care Plans
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for five residents regarding their Code Status preferences. This deficiency was identified during a review of the facility's policy on comprehensive care plans, which mandates that all residents have a baseline care plan completed and a comprehensive care plan in the electronic chart within seven days of the completion of the Admission MDS assessment. The care plans are intended to provide staff with guidelines on resident care needs. For Resident #4, the record review revealed that the resident had several medical conditions, including dementia and Parkinson's disease, and required assistance with all care. Despite having a Code Status form indicating preferences against CPR, use of respirators, ventilators, tube feeding, and transfer to an acute care hospital, these preferences were not included in the resident's comprehensive care plan. Similarly, Resident #17, who had severe cognitive impairment and multiple medical conditions, had specific Code Status preferences that were not reflected in their care plan, including no CPR, no use of a respirator/ventilator, and no transfer to an acute hospital, except for specific conditions. The deficiency extended to Residents #22, #66, and #68, who also had their Code Status preferences omitted from their care plans. Resident #22, with moderate cognitive decline, had a Do-Not-Resuscitate order that was not included in their care plan. Resident #66, who had full cognitive abilities, had preferences for CPR and other interventions that were not documented in their care plan. Lastly, Resident #68, who had full cognitive abilities and a DNR order, also had their preferences omitted from the care plan. The Social Services Director acknowledged that the residents' code status was not care planned, indicating a systemic issue in the facility's care planning process.
Improper Catheter Management and Infection Control
Penalty
Summary
The facility failed to adhere to its policy for indwelling catheter use, affecting five residents. Observations revealed that catheter bags were improperly positioned, with dignity bags touching the floor, which is against the facility's policy. For instance, Resident #52's catheter bag was observed hanging below the bed, covered by a dignity bag, but there was no documentation of the catheter size used during a recent change. Similarly, Resident #106's dignity bag was resting on the floor, and there was a discrepancy between the catheter size documented in the care plan and the size used during a recent change. Resident #17's catheter bag was observed on the floor, with the bag bent, preventing free urine flow. The care plan for this resident was not updated to reflect the correct positioning of the catheter bag. Resident #22's catheter bag was also found on the floor, with cloudy urine observed in the tubing, and the care plan lacked instructions to keep the bag off the floor. Additionally, Resident #51's catheter bag was resting on the floor, and there was no guidance on when to change the bag cover or keep it off the floor. The facility's policy requires that catheter use be in accordance with physician orders, including catheter size and frequency of change, and that collection bags be kept off the floor. However, the physician orders for several residents did not specify catheter sizes, and the care plans were not consistently updated to reflect changes or proper catheter care. These deficiencies contributed to recurrent urinary tract infections among the residents, as the facility did not ensure proper catheter management and adherence to infection control protocols.
Improper Storage and Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and medical supplies in accordance with professional standards, as observed in two of five medication rooms. During a tour of the Second Redwood Medication Room, expired medications and medical supplies were found, including ProSource NoCarb Protein, UTI-Stat, Aspirin, Prevacid for a specific resident, a Universal Viral Transport for Covid, an oral dispenser syringe, an IV catheter, and Point-Lok Sharps Safety devices. The Unit Manager RN confirmed the expiration of these items and indicated they would be disposed of. Additionally, vaccines were improperly stored on the top shelf of the refrigerator with other medications, and temperature monitoring was only documented once per day, contrary to CDC recommendations. In the Second Hickory Medication Room, further expired medications were discovered, including Vitamin E softgels, Acetaminophen tablets, Geri-kot stool softener, and Banatrol Plus anti-diarrheal solution. The facility's policy on the storage and labeling of medications and biologics, which was reviewed in December 2023, mandates that all medications be stored according to the manufacturer's recommendations and that expiration dates be monitored to prevent the use of expired medications. The CDC's Vaccine Storage and Handling Toolkit also requires that storage unit temperatures be checked and recorded at least twice per workday, which was not adhered to in this facility.
Failure to Provide Dignified and Respectful Care
Penalty
Summary
The facility failed to provide dignified and respectful care to two residents, resulting in a deficiency. Resident #96, who has Alzheimer's disease, dementia, intervertebral disc disorders, osteoarthritis, and a history of falls, was observed in the dining room expressing discomfort by repeatedly saying, 'Oh my back.' Despite the presence of staff members, including a CNA, no one acknowledged or responded to the resident's verbalization of pain. The resident's care plan included interventions for pain assessment and monitoring, yet the Medication Administration Record indicated a pain level of zero, and there was no documentation of the resident's discomfort in the progress notes. Resident #114, also diagnosed with Alzheimer's disease, dementia, and hypertension, was observed with unkempt hair and appeared confused. The resident expressed a desire to lay down, stating they were tired and gesturing towards a CNA who did not respond. Another CNA was called but also did not provide a response, only stating that dinner would be served soon. Eventually, the resident was assisted to their room and observed in bed. The facility's policy on resident rights emphasizes the right to a dignified existence and self-determination, which was not upheld in these instances. The Director of Nursing was interviewed and acknowledged the expectation for staff to respond to residents' needs. However, there was no explanation provided for the lack of response to Resident #96's pain or Resident #114's request to lay down. The facility's failure to acknowledge and respond to the residents' verbalizations of discomfort and care needs resulted in a deficiency, as it did not align with the facility's policy on maintaining residents' dignity and respect.
Failure to Prevent Resident Injuries
Penalty
Summary
The facility failed to ensure a safe environment for a resident, resulting in repeated skin tears and bruising. The resident, who had a history of falls and multiple medical conditions including Alzheimer's and heart disease, was observed with protective arm sleeves due to attempts to climb out of bed. Despite these measures, the resident continued to suffer from skin tears and bruises, some of which were attributed to bumping into bed rails and during transfers. The resident experienced two falls within the year, with one incident resulting in a head laceration requiring staples. Additionally, the resident sustained 13 skin tears and bruises over a period of several months. Some injuries occurred during transfers with a mechanical lift, raising concerns about the adequacy of supervision and assistance provided during these transfers. The care plan indicated the use of a Hoyer lift with one-person assistance, but it was unclear if this was sufficient given the resident's dependency. The facility's policies on skin care and fall risk management were reviewed, but they did not adequately address the investigation of causes for injuries other than falls. The Quality Nurse acknowledged the resident's confusion and attempts to get out of bed, but there was no clear explanation for injuries potentially caused by mobility bars or during transfers. The facility's failure to identify and mitigate these hazards contributed to the resident's repeated injuries.
Failure to Maintain Proper Head of Bed Elevation During Tube Feeding
Penalty
Summary
The facility failed to update and follow care planned interventions for a resident with a feeding tube, resulting in a deficiency. The resident, who was readmitted with diagnoses including dysphagia, multiple sclerosis, and pneumonitis due to inhalation of food and vomit, required extensive assistance with activities of daily living and had intact cognition. Physician orders specified that the head of the bed (HOB) should be elevated to 30 degrees during and after tube feeding to prevent complications. However, during an observation, it was found that the HOB was only at a 19-degree incline while the tube feeding was running. The care plan and Kardex indicated that yellow markings should be lined up to ensure the correct HOB elevation, but these markings were not visible during the observation. Nurse M confirmed the absence of the yellow tape and was unsure if the top of the mattress or the bed frame should align with the faint line on the headboard. This lack of clarity and failure to maintain the prescribed HOB elevation during tube feeding posed a risk of decreased tube feeding dose, aspiration, and/or pneumonia for the resident.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to follow physician's orders for oxygen administration for a resident diagnosed with COPD, chronic pulmonary edema, anxiety, and anemia. The resident was observed receiving oxygen at a flow rate of 3 liters per minute (LPM) via nasal cannula, which did not match the Kardex or care plan that specified a continuous oxygen flow rate of 2 LPM. The resident confirmed using oxygen continuously at 3 LPM, and the oxygen concentrator was set to this rate, with the humidification bottle found empty. Interviews with staff revealed inconsistencies in how oxygen flow rates were managed and communicated. A CNA stated that nurses set the oxygen flow rate, and aides were not allowed to change it. The CNA would check the Kardex or physician orders to verify the correct rate. However, the Kardex indicated a different rate than what was being administered. An RN explained that nurses have a standing order to titrate oxygen between 1-6 LPM based on the resident's needs and that CNAs would confirm the rate with nurses. The facility's policy requires following physician orders for oxygen flow rate and monitoring oxygen saturation every shift, but these protocols were not adhered to in this case.
Failure to Implement Yearly QAPI Plan
Penalty
Summary
The facility failed to implement a yearly Quality Assessment Process Improvement (QAPI) Plan tailored to the specific needs and concerns of its resident population, which includes 127 residents. This failure was identified during an interview and record review, where it was found that the facility's QAPI committee did not meet the required standards. The Administrator, who oversees the QAPI program, admitted that the committee met monthly except for December and claimed they met the quarterly meeting requirements. However, the documentation provided did not meet the attendee requirements as the Medical Director/Physician was absent from one of the meetings. Furthermore, the Administrator was unable to provide original attendance documents and instead provided a typed document that met the quarterly requirement. Additionally, the Administrator was unable to clearly articulate the processes for identifying areas of focus for improvement, stating only that the committee focused on Quality measures without providing specifics. When questioned about the completion of a yearly performance improvement project (PIP), the Administrator initially stated that no PIP had been completed. After further clarification, he suggested that a PIP might have been completed but was unable to provide any further information before the survey exit. This lack of a specific and implemented QAPI plan poses a potential risk for negative physical and psychosocial outcomes for all residents.
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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 Caro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fisher Senior Care And Rehabilitation | 11.1 mi | — | 0 | 0 |
| Medilodge Of Cass City | 12.5 mi | — | 0 | 0 |
| Marlette Community Hospital Ltcu | 19.4 mi | — | 0 | 0 |
| Medilodge Of Frankenmuth | 21.3 mi | — | 1 | 0 |
| Wellspring Lutheran Services | 21.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.