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Health Inspection Summary

Lapeer County Medical Care Fac

1455 Suncrest Dr

Lapeer, MI 48446

(810) 664-8571

Deficiency Category	Inspection Date: 12/19/23 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 9/22/22 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 2/13/20 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	2	1	1
Quality of Life and Care Deficiencies	5	6	5
Infection Control Deficiencies	1	1	1
Resident Assessment and Care Planning Deficiencies	2	0	1
Nursing and Physician Services Deficiencies	1	1	0
Resident Rights Deficiencies	2	4	3
Nutrition and Dietary Deficiencies	0	1	1
Pharmacy Service Deficiencies	3	1	2
Environmental Deficiencies	0	1	0
Administration Deficiencies	0	0	0

Detailed result for inspection on 12/19/23

Date of last standard health inspection:	12/19/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	7/31/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	16
Average number of Health Deficiencies in Michigan:	10.9
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide safe and appropriate respiratory care for a resident when needed.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	7/31/24	9/3/24	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/19/23	1/26/24	3 - Actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Some
Provide care and assistance to perform activities of daily living for any resident who is unable.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Allow resident to participate in the development and implementation of his or her person-centered plan of care.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few
Ensure each resident’s drug regimen must be free from unnecessary drugs.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 9/22/22

Date of last standard health inspection:	9/22/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	12/19/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	16
Average number of Health Deficiencies in Michigan:	11.2
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	9/22/22	11/8/22	3 - Actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	9/22/22	11/8/22	3 - Actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	9/22/22	11/8/22	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 2/13/20

Date of last standard health inspection:	2/13/20Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	2/22/23Read the full report (PDF) 9/26/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	9/26/22Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	14
Average number of Health Deficiencies in Michigan:	13
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	9/26/22	11/8/22	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide for the safe, appropriate administration of IV fluids for a resident when needed.	2/13/20	3/23/20	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	2/22/23	3/31/23	3 - Actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	2/22/23	3/31/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	9/26/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	2/22/23	3/31/23	3 - Actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	2/13/20	3/23/20	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	2/13/20	3/23/20	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Allow resident to participate in the development and implementation of his or her person-centered plan of care.	2/13/20	3/23/20	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	2/22/23	3/31/23	2 - Minimal harm or potential for actual harm	Few
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	2/13/20	3/23/20	1 - Potential for minimal harm	Many

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	2/13/20	3/23/20	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	2/13/20	3/23/20	2 - Minimal harm or potential for actual harm	Few
Ensure that residents are free from significant medication errors.	2/13/20	3/23/20	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	7/31/24	9/3/24	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Some
Allow resident to participate in the development and implementation of his or her person-centered plan of care.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	12/19/23	1/26/24	2 - Minimal harm or potential for actual harm	Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	9/26/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	2/22/23	3/31/23	3 - Actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	2/22/23	3/31/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	9/26/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	2/22/23	3/31/23	3 - Actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	2/22/23	3/31/23	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	9/26/22	11/8/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	9/26/22	11/8/22	2 - Minimal harm or potential for actual harm	Few

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