No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Ashley Healthcare Center

103 West Wallace Street, Ashley, MI 48806 · For profit - Limited Liability company · 63 certified beds · (989) 847-2011 Medicare & Medicaid certified

Call the home — (989) 847-2011 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 20252 actual-harm citations$70,904 in federal fines2 Medicare payment denials
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $70,904 in federal fines (most recent 2025-08-13)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
320 S Sterling St · (989) 847-2621 · Call to confirm hours
Pharmacy
Rite Aid9.5 mi
1010 E Center St · (989) 875-3380 · Call to confirm hours
Grocery
3133 Willowbrook Rd · (989) 224-3117 · Call to confirm hours
Park
3181 E Johnson Rd · (989) 875-5278 · Typically dawn to dusk
Place of worship
201 S Park St

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-04 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.1%10.8%15.4%worse
Long-stay residents who lose too much weight6.6%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder2.3%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms8.5%4.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury9.1%3.0%3.3%worse
Long-stay residents whose ability to walk worsened12.2%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.0%19.4%18.9%typical
Long-stay residents given the seasonal flu vaccine82.0%95.0%95.3%worse
Long-stay residents with pressure ulcers8.7%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control28.9%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table54.8%14.8%17.1%check this — see note marked dagger below the table
Short-stay residents who newly got an antipsychotic medication5.1%1.1%1.4%worse
Short-stay residents given the seasonal flu vaccine25.9%79.5%79.4%worse
Short-stay residents rehospitalized after admission26.5%24.0%22.6%worse
Short-stay residents with an outpatient ER visit11.9%11.7%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.671.841.67typical
Long-stay outpatient ER visits per 1,000 resident days3.201.641.80worse

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

12.1%U.S. median 10.7%
Went back to hospital
0.13U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 37% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.1%CMS range 7.4–17.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.82
RN hours/ resident / day
0.30
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.25
Total nurse hours/ resident / day
0.54
RN hoursweekends
50.9%
Total nursing turnover
53.8%
RN turnover

How full it usually is: this home is certified for 63 beds and averages 52.9 residents a day — about 84% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.81 hrs/resident/day on weekends vs 3.43 on weekdays — 18% thinner on weekends. RN hours go from 0.93 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

13
deficiencies at the latest standard inspection (2026-02-25)
4
at the previous standard inspection (2025-01-09)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2025-08-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2579353. Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for 1 resident (R203) of three residents reviewed for falls resulting in R203 falling from her raised bed to the floor and sustaining a fracture of her femur. Findings include:Review of an admission Record revealed R203 admitted to the facility on [DATE] with pertinent diagnoses which included autism, anxiety, and developmental disorder. Review of current fall Care Plan interventions for R203, with a start date of 3/11/2025, directed staff to utilize a fall mat on the left side of bed and keep bed in lowest position when not providing care. Further review revealed another intervention started 3/8/2025 directed staff to keep frequently used items including the call light within reach while in room. Review of MI-FRI #61119 facility investigation report revealed R203 fell from her raised bed to the floor the afternoon of 7/20/2025 when Certified Nursing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-07-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00153789 and #MI00152893 Based on interview and record review, the facility failed to provide quality care to one of three residents reviewed (Resident #100) resulting in the delay of on-going assessments including pain assessments and providing adequate pain relief, the initiation of potential hip fracture mobility interventions, and emergency medical treatment, following a fall that resulted in a fractured hip. Findings: Resident #100 (R100) Review of a Face Sheet revealed R100 was an [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's disease. Review of a Brief Interview for Mental Status (BIMS) completed on 06/16/25 reflected a score of 4 out of 15, that indicated R100 had severe cognitive impairment. During an interview on 06/25/25 at 11:45 AM, R100's durable power of attorney (DPOA)/family member K stated that on 06/17/25 around 2:08 PM the facility called and reported that R100 (a) had fallen sometime around 1:30 PM that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0578 — failed to honor advance directives / code status — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document the code status for 1 resident (R18) of 1 resident reviewed for advance directives.Findings include:Review of an admission Record revealed R18 admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia and dependence on supplemental oxygen. Further review revealed he had a court appointed guardian.Review of R18's Care Conference Report note, dated 1/7/2026, revealed he planned to continue as full code status (full resuscitation and life sustaining treatment).Review of R18's Resident Code Status form, signed by his court appointed guardian 6/27/2025, revealed he wished to be full code.Review of R18's Physician's Orders, active 2/23/2026 revealed an order for R18 to be DNR (Do Not Resuscitate).In an interview on 2/23/2026 at 2:25 PM, Registered Nurse (RN) K stated I think he (R18) is full code. RN K then viewed his Medication Administration Record alert and Physician's Orders and reported he was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the discharge needs were met for 1 resident (R23) of two residents reviewed for discharge concerns. Findings include:Review of an admission Record revealed R23 admitted to the facility on [DATE] with pertinent diagnoses which included type II diabetes mellitus, major depressive disorder, and hoarding disorder. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R23, with a reference date of 10/11/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R23 was cognitively intact. In an interview on 2/23/26 at 10:00 AM, R23 reported that she did not belong at the facility. R23 stated she was quite a distance from her home, and she had requested multiple times that she would like to move closer to where her family resides, possibly in a senior apartment. R23 reported that she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a patient centered care plan for pain and pressure ulcers for 1 Resident (R1) of 13 residents reviewed for care plans.Findings included: Review of R1's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: osteomyelitis, pressure ulcer of right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of unspecified part of back, unstageable. He was his own responsible party.During an interview with R1 in his room on 1/23/26 at 1:20 PM, R1 complained about staff not getting him placed correctly in bed. R1 said he is 6 feet tall, and staff do not get him high enough into bed. R1 was sitting in a recliner next to his bed during this interview. R1 said when staff put him on the bed his butt is not placed high enough for him to bend properly and it causes more pain to his tailbone. R1 said staff do not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician orders to treat and monitor health conditions for 1 Resident (R2) of 1 Resident reviewed for medical complaints.Findings included: Review of R2's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: mild cognitive impairment, atypical facial pain, post-traumatic stress disorder and mild neurocognitive disorder. R2 was not his own responsible party.During an interview with R2 on 2/23/26 at 11:38 AM, R2 complained about his right ear hurting and buzzing. R2 said he has reported it to staff, but nothing is being done about it.During an interview with facility Social Worker (SW) A, SW A said R2 had complained about his ears ringing sometime in the last week. The Surveyor requested information on how the facility followed up with R2's concerns about his right ear.On 2/24/26 at 1:08 PM, Social Worker A provided a note form R2's physician dated 1/14/26,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to recognize, assess and respond to an acute change of condition for 1 (R29) resident of 2 residents reviewed for change of condition. Findings include:Review of an admission Record revealed R29 originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia, psychotic disturbance, anxiety, and insomnia. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R29, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13, out of a total possible score of 15, which indicated R29 was cognitively intact. Further documentation revealed was there evidence of an acute change in mental status from the resident's baseline, marked yes. Review of a Resident Code Status dated [DATE] revealed R29 was a Full code (Full resuscitation and life sustaining treatment desired). Review of a Hospice…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to thoroughly assess skin on admission, do ongoing assessments, implement an effective treatment plan, and prevent the worsening of pressure ulcers for 1 resident (R1) of 2 residents reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer.Findings included:A review of R1's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included osteomyelitis, pressure ulcer of the right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of an unspecified part of the back, unstageable. He was his own responsible party.During an interview with R1 in his room on 1/23/26 at 1:20 PM, R1 complained about staff not getting him placed correctly in bed. R1 said he is 6 feet tall, and they do not get him high enough into bed. R1 was sitting in a recliner next to his bed during this interview. R1 said when staff…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to assess, monitor and implement a respiratory care plan for 1 Resident (R1) on Continuous Positive Airway Pressure (CPAP). Findings include: Review of R1's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: osteomyelitis, pressure ulcer of the right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of unspecified part of back, unstageable. He was his own responsible party. During an interview conducted on 1/23/26 at 1:20 PM in his room, R1 complained that the facility never cleaned his CPAP machine or provided cleaning equipment or supplies. Review of R1's medical record did not reveal a physician order for the use of the CPAP machine or its care and cleaning. Further review of the medical record did not reveal a respiratory care plan for the use and care of the CPAP machine or ongoing respiratory…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to adequately treat 1 Resident (R1) for pain of 1 Resident reviewed for pain.Findings included: Review of R1's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: osteomyelitis, pressure ulcer of right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of unspecified part of back, unstageable. He was his own responsible party.During an interview with R1 in his room on 1/23/26 at 1:20 PM R1 complained about staff not getting him placed correctly in bed. R1 said he is 6 feet tall, and staff do not get him high enough into bed. R1 was sitting in a recliner next to his bed during this interview. R1 said when staff put him on the bed his butt is not placed high enough for him to bend properly and it causes more pain to his tailbone. R1 said staff do not listen or assist him in becoming more comfortable. R1 said…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide laboratory services to meet the needs of one resident (R9) of one resident reviewed for laboratory services. Findings include:Review of the Electronic Medical Record (EMR) admission record reflected R9 was admitted to the facility 9/18/2025 with diagnoses that included bipolar disorder.Review of the EMR Progress Notes for R9 reflected an entry dated 2/19/2026 at 9:44 AM. The entry reflected, (Name of Physician) in to evaluate and treat patient for recent increase in behaviors. Gave order to perform urinalysis and collect (comprehensive metabolic panel (CMP) serum blood draw) Orders entered. Will collect urine.Review of the EMR Physician Orders for R9 did not reveal the orders had been entered as indicated by the Progress Note of 2/19/2026 at 9:44 AM.Further review of the EMR did not reveal any further documentation that lab specimens were obtained, lab results, monitoring for lab results, or attempts to determine the root cause of the recent increase in behaviors of R9.On 2/25/2026 at 1:25 PM, an interview was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an accurate, clear, and concise Electronic Medical Record (EMR) for 2 residents (R18, and R9) of 14 residents reviewed.Findings include:R9 Review of the Electronic Medical Record (EMR) admission record reflected R9 was admitted to the facility 9/18/2025 with diagnoses that included bipolar disorder. Review of the EMR Progress Notes for R9 reflected an entry dated 2/19/2026 at 9:44 AM. The entry reflected, (Name of Physician) in to evaluate and treat patient for recent increase in behaviors. Gave order to perform urinalysis and collect (comprehensive metabolic panel (CMP) serum blood draw) Orders entered. Will collect urine. Review of the EMR Physician Orders for R9 did not reveal the orders had been entered as indicated by the Progress Note of 2/19/2026 at 9:44 AM. Further review of the EMR did not reveal any further documentation that lab specimens were obtained, of lab results, monitoring of the Resident, monitoring for lab results, or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2026-02-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to clean 1 resident's (R1) Continuous Positive Airway Pressure (CPAP) machine of 1 Resident on CPAP.Findings included: Review of R1's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: osteomyelitis, pressure ulcer of the right upper back, urinary tract infection, diabetes mellitus, morbid (severe) obesity, chronic pain, and pressure ulcer of unspecified part of the back, unstageable. He was his own responsible party.During an interview with R1 in his room on 1/23/26 at 1:20 PM, R1 reported that he cleaned and cared for his Continuous Positive Airway Pressure (CPAP) machine when he was at home, but no one has cleaned it since he was admitted to the facility. No cleaning equipment or supplies were visible in the room, and the machine was sitting on the windowsill with the tube still connected to the machine.During an interview with the Director of Nursing (DON) on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to operationalize the facility infection control policy to provide influenza and pneumococcal vaccines timely for two newly admitted Residents (R1 and R21) of six residents reviewed for immunizations. Findings include:R1Review of the Electronic Medical Record (EMR) admission record reflected R1 was admitted to the facility 1/27/2026 and made their own medical decisions.Review of the EMR for R1 revealed the facility document titled Resident - Vaccine Consent. The document dated 1/28/2026 reflected R1 has signed the consent form to accept the influenza and pneumonia vaccines.Review of the EMR Physicians Orders for R1 reflected an order dated 2/2/2026 May have Pneumococcal and May have annual Influenza Vaccine and to administer vaccines to patients who have not already received it unless contraindicated.Review of the EMR immunization record of R1 reflected documentation of the Mantoux Skin Test but no immunizations for influenza or pneumonia.Review of the Progress Notes for R1 did not reveal documentation the influenza and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to operationalize the facility infection control policy to provide Covid-19 vaccine timely for two newly admitted Residents (R1 and R21) of six residents reviewed for immunizations and failed to implement a process to track and monitor staff Covid-19 education and immunization status. Findings include:R1Review of the Electronic Medical Record (EMR) admission record reflected R1 was admitted to the facility 1/27/2026 and made their own medical decisions.Review of the EMR for R1 revealed the facility document titled Resident - Vaccine Consent. The document dated 1/28/2026 reflected R1 had signed the consent form to accept the Covid-19 Series/Vaccine and the Recommended Annual Covid -19 Booster.Review of the EMR Physicians Orders for R1 reflected an order dated 2/2/2026 to administer vaccines requested to patients who have not already received it unless contraindicated.Review of the EMR immunization record of R1 did not reflect the Covid-19 series/vaccine had been initiated.Review of the Progress Notes for R1 did not reveal the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2621833Based on interview and record review, the facility failed to protect the resident's (Resident #301) right to be free from physical abuse by a resident (Resident #300).Findings:Resident #300 (R300)Review of an admission Record revealed R300 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: major depressive disorder severe along with major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance and Psychotic Mood Disorder including mania and depression with psychotic features (per her psychiatric evaluation note).Review of R300's hospital Discharge Summary Note dated 8/19/25 revealed, .The patient was brought into the ER (emergency room) on 5/6/25 by her sister who reported that the patient has been aggressive and acting out more at home. On day of discharge, the patient was doing fair. There was no hallucinations or suicidal or homicidal ideation or intent. She had no physical agitation or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-13 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2621833Based on interview and record review, the facility failed to implement their abuse policy resulting in an allegation of physical abuse to go unreported with no investigation.Findings:Resident #203 (R203)Review of an admission Record revealed R203 was a [AGE] year-old female, admitted to the facility on [DATE].Resident #300 (R300)Review of an admission Record revealed R300 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: major depressive disorder severe along with major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance and Psychotic Mood Disorder including mania and depression with psychotic features (per her psychiatric evaluation note).Review of R300's Progress Note dated 09/03/2025 at 12:47 AM written by Registered Nurse (RN) J revealed, .Writer was called to the East Hallway, stated that this Resident heat (hit [sic]) her room mate (sic) on her L (left) hand, she denies the incident.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 resident (R203) of 7 residents reviewed. Findings include:Review of an admission Record revealed R203 admitted to the facility on [DATE] with pertinent diagnoses which included autism, anxiety, and gastrostomy. Review of current Care Plan interventions for R203, with a start date of 4/10/2025, revealed R203 was on EBP and directed staff to follow Centers for Disease Control guidelines. Review of R203's Physician's Orders revealed an active order for EBP started 4/8/2025. Further review revealed R203 required tube feedings through a gastrostomy. Review of facility policy/procedure Enhance Barrier Precautions, revised 2/26/2025, revealed .an order for enhanced barrier precautions will be obtained for residents with any of the following. feeding tubes. make gown and gloves available immediately near or outside of the resident's room. PPE (Personal Protective Equipment) is only necessary when…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0761 — failed to label and store drugs safely — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to monitor for outdated medications and maintain proper storage of insulin in the facility medication room refrigerator, resulting in the storage of discontinued and outdated insulin and the potential for outdated medication to be administered to facility residents. Findings: On 1/8/25 at 10:22 AM a review of the medication room refrigerator was conducted with Registered Nurse (RN) F. The review revealed a vial of Novolin N for R37 dated as opened and placed in service on 9/1/24. RN F reported this medication had been discontinued and should have been discarded. Review of the Doctor's Orders for R37 reflected Humulin N had been ordered for R37 on 8/31/24 and discontinued on 9/2/24. Review of the manufacturer's package insert for Novolin N reflected, Novolin® N in use: Vials Keep at room temperature below 77°F (25°C) for up to 6 weeks (42 days) . Throw away an opened vial after 6 weeks (42 days) of use, even if there is insulin left in the vial. The policy provided by the facility titled Medication Storage, last…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control procedures in one room (room [ROOM NUMBER]) and for 3 of 6 residents ( R37, R48, and R52) in isolation for COVID-19, potentially affecting 14 of 51 residents, resulting in the potential for cross contamination and the spread of COVID-19. Findings include: R37 A review of R37's Face Sheet, undated, revealed R37 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R37's Face Sheet revealed multiple diagnoses that included dementia, anxiety, and depression. A review of the facility's CMS (Centers for Medicare and Medicaid Services) Form 802, undated but provided to the survey team on 1/7/25, revealed R37 was listed as having COVID under the Infections column. During an observation on 01/08/25 at 08:30 AM, R37's room door was wide open, and staff were not visible in the room. There was a sign on the outside of R37's room door that revealed staff were to use Airborne Contact…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one Resident (R206) was provided adequate, accessible hydration. Findings: Review of the medical record reflected R206 admitted to the facility 12/19/24 with diagnoses that included heart and kidney failure. The medical record reflected R206 admitted to hospice on 12/26/24. The Care Plan reflected the Resident required extensive assistance with transfer and bed mobility. On 1/7/25 at 3:28 PM, R206 was observed in her bed sleeping with her mouth open. It was observed that her lips were dry and peeling and her tongue appeared dry. On 1/8/25 at 2:07 PM, R206 was asleep in her bed and her water cup was on an over-the-bed table which was pulled away from the bed well out of reach of the Resident On 1/9/25 at 8:19 AM, R206 was observed in bed, uncovered, with the blanket on the floor next to the bed. Her water cup was observed on a night stand out of her reach and the call light button was observed on the floor next to the bed out of sight and reach for the Resident. R206 presented with tenting of the skin…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to notify the hospice service of a change in the plan of care for one resident (R206) after a fall and Care Plan changes had been implemented. Findings: Review of the medical record reflected R206 admitted to the facility 12/19/24 with diagnoses that included heart and kidney failure. The medical record reflected R206 began hospice services on 12/26/24. On 1/8/25 at 2:07 PM, R206 was observed laying in a low bed with a fall mat next to the bed. R206 had a large dressing secured to her upper forehead. Review of the medical record reflected an entry on 1/8/25 at 12:21 PM by Registered Nurse (RN) G that R206 had fallen and sustained a laceration to her right forehead. The entry reflected steri-strips and a dressing was applied to the wound. Care Plan changes were documented and implemented. The entry reflected the responsible party and the physician were notified. The documentation did not reflect hospice services was notified and informed of the fall and the change in the plan of care. On 1/9/25 at 11:32 AM a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-31 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1) ensure proper posting of Enhanced Barrier Precaution (EBP) and Transmission Based Precaution (TBP) signage, 2) ensure proper use of Personal Protective Equipment (PPE), and 3) ensure prevention of contamination of treatment supplies and the treatment cart for 2 residents (Resident #33 and #394) of 3 residents reviewed for Transmission Based Precautions, resulting in the increased potential for cross-contamination, bacterial harborage and spread of infection throughout the facility. Findings include: Resident #33 Review of an admission Record revealed Resident #33 admitted to the facility on [DATE] with pertinent diagnoses which included legal blindness and obstructive and reflux uropathy. Review of Resident #33's Physician's Orders, dated 4/12/2024, revealed an active order for EBP's. Review of a current EBP Care Plan problem/approach for Resident #33, edited 5/2/2024, directed staff to use gloves and a gown with urostomy/Foley care.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean environment for 1 Resident #29 (R29) of 14 residents reviewed for clean environment, resulting in a consistent offensive odor coming from R29's bathroom. Findings include: R29 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R29 was admitted to the facility on [DATE], with diagnosis of (but not limited to) Dementia (short and long-term memory impairment). Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represented R29 had severe cognitive impairment. R29 required the assistance of 1 staff member with all activities of daily living. R29 was unable to answer questions related to the offensive odor and therefore the reasonable person will be applied to this concern. During the initial tour of the facility on 7/29/24 at approximately 10:10 AM there was a strong urine smell coming from room [ROOM NUMBER] that was more noticeable in the bathroom. During a subsequent…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-31 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an accurate health record for 1 resident (Resident #33) of 14 residents reviewed for accuracy of medical records, resulting in unclear documentation and the potential for miscommunication and an unclear picture of the resident's health care status. Findings include: Resident #33 Review of an admission Record revealed Resident #33 admitted to the facility on [DATE] with pertinent diagnoses which included legal blindness and obstructive and reflux uropathy. Review of Resident #33's physician communication form, dated 7/22/2024, revealed .Concerns: Resident only wants to see doctor about his pain (with) foley catheter (and) red collection drainage . Doctor Recommendation: Do (urinalysis) please . Review of Resident #33's nursing Progress Note, dated 7/23/2024 at 11:04 AM, revealed Registered Nurse (RN) A notified the physician of Resident #33's complaint of pain around his catheter site and bloody urine and received a physician order for a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-15 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights and fluids were within reach for 2 residents (Resident #49 and Resident #12) out of 3 resident reviewed for accommodation of needs. Findings: Resident #49 (R49) Review of a face sheet revealed R49 was a [AGE] year-old-male, admitted to the facility on [DATE] with pertinent diagnoses of dementia, seizure disorder, and protein-calorie malnutrition. Review of a Brief Interview for Mental Status (BIMS) dated 11-16-23 revealed R49 had severe cognitive impairment. During an observation on 02/12/24 at 10:00 AM, R49 laid resting in bed, the call light was looped over the bed frame and down between the metal slates of the frame; out of sight and out of reach of the resident. The over bed table with a cup of fluids sat near the room dividing curtain and out of reach of the resident. During an observation on 02/12/24 at 12:01 PM, R49 laid resting in bed with eyes closed and the call light and cup of fluids remained out of reach of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-15 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00139878, MI00139961, MI00141377, MI00142340. Based on interview and record review, the facility failed to report an allegation of abuse timely to the state agency and law enforcement for 6 of 6 residents, Resident #25, #35, #43, #52, #106, and #109 (R25, R35, R43, R52, R106 and R109) reviewed for timely reporting. This deficient practice resulted in allegations of abuse with injury and serious injury to go unreported to local law enforcement and uninvestigated. Findings include: The facility provided a copy of the Abuse, Neglect and Exploitation dated 11/1/2022 for review. The policy reflected, IV. Identification of Abuse, Neglect, and Exploitation .1. Resident, staff, or family report of abuse .3. Physical injury of a resident, of unknown source .VII. Reporting/Response .1. Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-15 · tag F0882 — pattern
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist was present to properly assess, implement, and manage the Infection Prevention and Control Plan during a COVID 19 outbreak. Findings: During the Infection Control review the facility provided the Infection Preventionist (IP) certificate that the Director of Nursing (DON) had attained on 2/21/2023. The facility also provided for review the IP certificate for the Nursing Home Administrator (NHA). However, the NHA did not provide documentation of the qualifying criteria for an IP. In an email response to a request for professional qualifications for an IP the NHA acknowledged that she did not meet the regulatory requirements of an IP. On 2/15/23 at 1:22 PM the Director of Human Resources (DHR) E reported that the DON was on leave from 10/7/23 through 12/13/23. During an interview conducted 2/15/24 at 2:15 PM the DON reported Registered Nurse (RN) S assumed the clinical duties of the IP while she was on leave. The DON reported that RN S is not certified as an IP. The DON indicated she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00139878 Based on interview, and record review the facility failed to follow the facility to thoroughly investigation abuse for 1 of 6 residents, Resident #106, (R106) reviewed for abuse. Findings include: The facility provided a copy of the Incidents and Accidents policy dated 11/1/2022 for review. The policy reflected, The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent reoccurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences .5. The following incidents/accidents require an incident/accident report but are not limited to .Alleged abuse .Combative behavior .Resident to resident altercations . Unobserved injuries . The facility provided a copy of the Abuse, Neglect and Exploitation dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$70,904 in federal fines across 2 penalties. 2 Medicare payment denials on record.

  • $17,686 — penalty dated 2025-08-13
  • $53,218 — penalty dated 2024-02-15
  • Medicare payment denial — starting 2025-09-10 for 15 days
  • Medicare payment denial — starting 2024-03-16 for 34 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PIONEER HEALTHCARE MANAGEMENT — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.3-1.3 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 4 of 53.0+1.0 vs chain
Quality measures 1 of 52.9-1.9 vs chain
The other 8 homes this chain runs (chain average 2.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
UDDIN, FAHIMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2021
ANDERSON, RUSSELLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2026
STEWART, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2026

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.1M
Net patient revenuemost recent cost report
-5.3%
Operating marginrevenue minus expenses
$519K
Related-party expense10% of expenses

This home reported $519K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$299per resident / day
operating cost
$9,084per month
≈ monthly operating cost
$284per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235532. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next