Lenawee Medical Care Facility
200 Sand Creek Highway · Adrian, MI · 49221 · 5172636794
113 certified beds Government - County
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
- 3 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 4 of 5 Inspections: 3 of 5 Staffing: 4 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 5.22 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.51 | 0.55–0.75 |
| Weekend hours / resident-day | 4.63 | ≈ weekday level |
| Nursing turnover / year | 49% | median 45% |
| Fines (3-yr window) | 1 · $15,593 |
Inspection citations (19 in the current record)
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Potential for harm · D March 19, 2026
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected April 17, 2026 · Resident Rights
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Potential for harm · D March 19, 2026
Keep residents' personal and medical records private and confidential.
Corrected April 17, 2026 · Resident Rights
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Potential for harm · D March 19, 2026
Assess the resident when there is a significant change in condition
Corrected April 17, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 19, 2026
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.
Corrected April 17, 2026 · Quality of Life and Care
-
Potential for harm · D March 19, 2026
Ensure medication error rates are not 5 percent or greater.
Corrected April 17, 2026 · Pharmacy Service
-
Potential for harm · D March 19, 2026
Provide and implement an infection prevention and control program.
Corrected April 17, 2026 · Infection Control
-
Potential for harm · E March 19, 2026 · found via complaint
Ensure that paid feeding assistants have the training they need.
Corrected April 17, 2026 · Nursing and Physician Services
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Potential for harm · D February 5, 2026 · found via complaint
Respond appropriately to all alleged violations.
Corrected March 2, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 22, 2025 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected December 11, 2025 · Resident Rights
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Actual harm · G June 25, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 29, 2025 · Quality of Life and Care
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Potential for harm · D June 25, 2025 · found via complaint
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected June 13, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D August 1, 2024 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected August 1, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Actual harm · G November 16, 2023
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected December 4, 2023 · Quality of Life and Care
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Potential for harm · D November 16, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 4, 2023 · Resident Assessment and Care Planning
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Potential for harm · D November 16, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 4, 2023 · Quality of Life and Care
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Potential for harm · D November 16, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 4, 2023 · Quality of Life and Care
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Potential for harm · D November 16, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 4, 2023 · Freedom from Abuse, Neglect, and Exploitation
-
No harm found · B November 16, 2023
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected December 4, 2023 · Resident Rights
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Actual harm · G October 19, 2023 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 20, 2023 · Freedom from Abuse, Neglect, and Exploitation
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 16, 2023 | Fine | $15,593 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 235224 · certified since August 1, 1973. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.