Lenawee Medical Care Facility
200 Sand Creek Highway, Adrian, MI 49221 · Lenawee County · 113 certified beds · avg 111 residents/day · certified since Aug 1, 1973
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 14, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 12, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 14, 2026 · F-0604 · triggered by a complaint
The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 12, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 25, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 29, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Nov 16, 2023 · F-0678
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 4, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 19, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 20, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (24)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 14, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 14, 2026 | ▲ G · Actual harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| May 14, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| May 14, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 14, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 19, 2026 | E · Potential for harm, repeated | The facility did not make sure that paid feeding assistants — staff hired to help residents eat and drink — had the training they need. · from a complaint |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 5, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 22, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jun 25, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 25, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. · from a complaint |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Nov 16, 2023 | ▲ G · Actual harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 16, 2023 | B · Minimal risk, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Oct 19, 2023 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 2 | G ▲ |
| 2024 | 1 | 0 | D |
| 2025 | 3 | 1 | G ▲ |
| 2026 | 13 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $15,593.
| Date | Type | Amount / length |
|---|---|---|
| Nov 16, 2023 | Fine | $15,593 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Michigan avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.83 | 4.32 | 3.95 | top 9% in Michigan; top 5% in the U.S. |
| Registered Nurse hours | 0.58 | 0.84 | 0.69 | bottom 26% in Michigan; bottom 49% in the U.S. |
| Weekend total nurse staffing | 5.08 | 3.79 | 3.50 | top 9% in Michigan; top 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.28 | 0.49 | 0.48 | bottom 25% in Michigan; bottom 29% in the U.S. |
| Total nursing staff turnover (%) | 50.5 | 44.1 | 45.8 | bottom 30% in Michigan; bottom 36% in the U.S. |
| RN turnover (%) | 35.0 | 39.2 | 42.9 | top 46% in Michigan; top 38% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.33, RN 0.53, weekend 4.65. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Government - County
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lenawee County | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/1970 |
| Blevins, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2025 |
| Blevins, Christina | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2025 |
| Concept Rehab, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Elledge, Sara | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/06/2017 |
| Graham, Amy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/14/2025 |
| Jones, Kristie | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2021 |
| Jones, Lindsey | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/18/2023 |
| Lenawee County | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/1970 |
| Lenawee County | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/1970 |
| Macnaughton, Thomas | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/18/2015 |
| Macnaughton, Thomas | Individual | ADP of the SNF | NOT APPLICABLE | 09/18/2015 |
| Maner, Costerisan & Ellis, PC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Michigan Post-Acute Medical Services 1 PC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Morrison Management Specialists INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/17/2022 |
| Reilly, Jennifer | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/17/2024 |
| Scarborough, Joyce | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/18/2024 |
| Tuckey, Erin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/27/2021 |
| Tuckey, Erin | Individual | ADP of the SNF | NOT APPLICABLE | 11/13/2025 |
| Vernier, Kirk | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/18/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Who helps residents eat at mealtimes, and what training have they completed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Springcreek Rehabilitation and Nursing Center | 0.2 mi | Adrian, MI | ★★☆☆☆ | 2/5 | |
| Lynwood Manor Healthcare Center | 1.9 mi | Adrian, MI | ★★★☆☆ | 3/5 | |
| Adrian Bay Rehabilitation and Nursing Center | 2.0 mi | Adrian, MI | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 235224.