01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-04 | 2 | 2025-09-04 | 0 |
| Cycle 2 | 2024-09-09 | 6 | 2024-09-09 | 1 |
| Cycle 3 | 2023-07-13 | 14 | 2023-07-13 | 0 |
CMS CCN 2355772026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Mclaren Lapeer Region
1375 North Main Street · Lapeer, MI 48446 · Lapeer County
Certified beds19CMS provider file
Recent citation rows23current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
23 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-04 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-09-252025-09-04 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-09-252024-09-09 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-09 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-09-26 · complaint2024-09-09 · HEALTHF0700Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Correction field: Deficient, Provider has date of correction · 2024-09-26 · complaint2024-09-09 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-09 · HEALTHF0868Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-09 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-09 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-09-262023-07-13 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0655Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0710Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0809Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0868Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Correction field: Deficient, Provider has date of correction · 2023-08-112023-07-13 · HEALTHF0947Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2023-08-1103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MCLAREN HEALTH CARE CORPORATIONOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/1992
- BURKE, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/30/2020
- BURROUGH, ERICIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2016
- GRANT, CHADIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/29/2019
- INCARNATI, PHILIPIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/1992
- NOUNOU, MAJEDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/19/2025
- RIEHL, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/19/2025
- SCOTT, JUSTUSIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2003
- SHARMA, VISHNUIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/19/2025
- SMITH, D. WESLEYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/19/2025
- DAVIS, TIFFANYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/19/2025
- VARGAS, TIMOTHYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/19/2025
- MCLAREN HEALTH CARE CORPORATIONOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/1992
- DAVIS, TIFFANYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/19/2025
- SHARMA, VISHNUIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/19/2025
- VARGAS, TIMOTHYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/19/2025
- BURKE, MICHAELIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 03/30/2020
- BURROUGH, ERICIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 01/01/2016
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours6.81per resident day
RN hours4.51per resident day
Weekend nurse hours5.81per resident day
Staff turnover45.5%CMS reported field