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Huron County Medical Care Facility

1116 South Van Dyke Road, Bad Axe, MI 48413 · Government - County · 112 certified beds · (989) 269-6425 Medicare & Medicaid certified

Call the home — (989) 269-6425 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1142 South Van Dyke Road, Suite 100
Pharmacy
721 N Van Dyke Rd · (989) 269-8061 · Call to confirm hours
Grocery
721 N Van Dyke Rd · (989) 269-7442 · Call to confirm hours
Park
210 S Hanselman St · (989) 269-2630 · Typically dawn to dusk
Place of worship
1200 S Thomas Rd · (517) 267-1161

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 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 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 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 rating5★
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 increased19.7%10.8%15.4%worse
Long-stay residents who lose too much weight2.6%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection3.0%1.5%2.0%worse
Long-stay residents with depressive symptoms2.9%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.0%3.0%3.3%better
Long-stay residents whose ability to walk worsened14.0%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.0%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine97.6%95.0%95.3%typical
Long-stay residents with pressure ulcers1.9%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control21.8%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table24.7%14.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.1%1.4%better
Short-stay residents rehospitalized after admission21.6%24.0%22.6%typical
Short-stay residents with an outpatient ER visit10.1%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days0.781.841.67better
Long-stay outpatient ER visits per 1,000 resident days1.901.641.80typical

§ 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.

57.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.1%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
62.9%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 62.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.43 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF57.1%CMS range 44.3–66.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.2–14.910.7%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 discharge62.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge34.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge65.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 3.7–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

0.71
RN hours/ resident / day
1.16
LPN hours/ resident / day
3.70
Aide hours/ resident / day
5.57
Total nurse hours/ resident / day
0.35
RN hoursweekends
36.1%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 112 beds and averages 70.2 residents a day — about 63% occupied, or roughly 42 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 5.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.70 is at or above 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 4.61 hrs/resident/day on weekends vs 5.96 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.85 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

4
deficiencies at the latest standard inspection (2025-07-17)
11
at the previous standard inspection (2024-07-10)

Deficiencies are fewer than at the previous inspection — improving. 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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Fcited before2025-07-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    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 maintain a sanitary kitchen, ensure that food items were dated with an opened date, that expired food was removed and/or disposed of, and that food temperatures were monitored prior to serving. This deficient practice had the potential to affect all residents who consume food prepared and served from the facility kitchen and kitchenettes of a census of 72 residents. On 7/15/25 at 10:00 AM, a tour of the kitchen was conducted with Dietary Manager C of the facility kitchen. The following items were observed:-The juice dispenser had juice in boxes that were connected to be dispensed. The boxes had a delivery date but did not have an open date. The DM was asked about facility policy and reported they should be dated. The DM reported there was a three-month shelf life after opened.-Cups and lids stacked and on a cart that was covered with a cloth, many of the cups and lids were stacked wet.-Plates were stacked and when observed with the DM, a couple of the plates were stacked wet and the tops for the plates were…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-17 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 develop a baseline care plan that provided person-centered care to meet the Resident's needs for one resident (Resident #81) of one resident reviewed for baseline care planning.Findings include: Findings include:Resident #81:A review of Resident #81's medical record revealed an admission into the facility on 6/30/25 with diagnoses that included acute respiratory failure with hypoxia, heart failure, and chronic obstructive pulmonary disease. On 7/15/25 at 2:35 PM, an observation was conducted of Resident #81 lying in bed with the head of the bed elevated. The Resident was interviewed, answered questions and engaged in conversation. The Resident was observed with oxygen on wall oxygen per nasal cannula. The Resident reported his oxygen should be at 2 Liters. An observation was made of the oxygen set at just above 2 liters and just under 2.5 liters. The Resident was asked if they had an intravenous (IV) catheter in their arm. The Resident…

    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 before2025-07-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 to ensure that a urinary catheter bag and tubing were secured off of the floor for one resident (Resident #6) of one resident reviewed for urinary catheters, resulting in contamination, an improperly secured catheter bag and tubing with the likelihood of infection. Finding include:Resident #6:On 7/15/2025, at 1:18 PM, Resident #6 was in the dining room in the wheelchair. They had a urinary catheter bag hooked under their wheelchair. The tubing was secured through their left pant leg near their ankle. There was approximately eight inches of catheter tubing resting on the floor. The catheter bag cover appeared to be touching the floor. On 7/16/2025, at 9:30 AM, a record review of Resident #6's electronic medical record revealed an admission on [DATE] with diagnoses of cancer, Anemia and obstructive uropathy. Resident #6 had severely impaired cognition and required extensive assistance with all Activities of Daily Living. On 7/16/2025, at 4:10 PM,…

    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 · Dcited before2025-07-17 · 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 observation, interview and record review the facility failed to ensure accurate physician's orders for oxygen administration for two residents (R38, R81) of two residents sampled for respiratory care, resulting in physician's orders without an oxygen flow rate. Resident #38 R38 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include pulmonary fibrosis, chronic obstructive pulmonary disease, acute respiratory failure and interstitial pulmonary disease. On 07/17/2025 at 11:39 AM, observation revealed an oxygen concentrator in the hall outside of the room of R38 it was administering oxygen at 6 liters per minute. On 07/17/2025 at 12:05 PM, record review of the physician's orders revealed an order for oxygen administration dated 07/03/2025 that read, Treatment Respiratory: Apply oxygen (per nasal cannula) to maintain O2 sat > or equal to 90%, AM, PM, NOC. The oxygen order did not specify an oxygen flow rate for R38. On 07/17/2025 at 12:25 PM, an interview was conducted with 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-01 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This Citation pertains to Intake Number MI00153947. Based on observation, interview and record review, the facility failed to follow the care plan and treat a resident with dignity for one resident (Resident #1) out of three residents reviewed for dignity, resulting in frustration, arguing and forceful removal from the activity room. Findings include: Resident #1: On 7/1/25, at 9:05 AM, a record review of the facility provided investigation file regarding the mistreatment of Resident #1 was conducted. The following staff statements revealed: The Assistant Activity Director (AAD) A's statement revealed . At first, it wasn't clear to me that they were seriously arguing, so I began assisting other residents . CNA F continued to argue with the resident, and removed her hands from the table and pushed her in her wheelchair out of the activity room . CNA E's statement revealed Today, after Bingo, around 3pm, (Resident #1) was refusing to leave the activity room . She said she paid for her chips and no one was going to take them away from her. She has a tendency to do this . (CNA F)…

    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 · Fcited before2024-07-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    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 maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 85 residents who receive meal services. Findings include: 1. On 7/8/24 at 11:02 AM, the floor in the walk in freezer was observed soiled and with visible debris on its surfaces. On 7/8/24 at 11:04 AM, a plastic container labeled as ground ham, and a bag of gluten free bread were observed on the floor underneath the wire rack shelving. Upon observation the surveyor inquired with Dietary Manager, staff A, on if they thought these areas were being cleaned timely and sufficiently to which they replied, yes, but our stock person comes in on Tuesdays and Fridays. They help with the cleaning and organizing. On 7/8/24 at 11:09 AM, broken eggshells and a container of heavy whipping cream were observed on the flooring in the walk in cooler. At this time the surveyor inquired with staff A on if they thought the flooring was being…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-10 · tag F0880 — failed to prevent and control infections — widespread
    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 ensure 1) Resident and employee illness surveillance and monitoring, 2) Perform hand hygiene and don personal protection equipment (PPE) prior to entering a transmission-based precautions room, 3) Supply the staff with a trash receptacle for a transmission-based precautions room, and 4) Ensure that a urinary catheter bag was off the floor for one resident (Resident #20), resulting in the likelihood of contamination and spread of illnesses. Findings include. On 7/09/24, at 2:14 PM, an observation of CNA D who entered room [ROOM NUMBER] without performing hand hygiene, donned gloves but no gown or mask. The door to room [ROOM NUMBER] hand a contact isolation sign attached to an isolation caddy that housed gowns, masks and gloves. There was an additional sign posted on the door that stated contact and droplet isolation. CNA E walked to doorway and asked CNA D, do we need to and CNA D interrupted and stated, no, that's for bed 1 (Resident…

    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 · Ecited before2024-07-10 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 residents were treated in a dignified manner for a Confidential Group of residents, from a group of 28 residents reviewed for dignity, resulting in residents having soiled briefs due to call lights not being answered timely, a lack of a functional outdoor patio, and no opportunity to spend their Bingo winnings due to a closed Bingo store. Findings Include: FACILITY On 7/09/24 at 2:03 PM, during a meeting with a Confidential Group of Residents, several residents on the 2nd and 3rd floors said on the 3rd shift (night shift), their call lights were not being answered timely. They said staff members would come in to answer the call light, but would turn off the call light, sometimes they would ask them what they needed and sometimes they would not, the staff would leave the room and usually not come back in to help them. Three residents said there were occasions when the staff member did not come back to assist them to the bathroom and the residents soiled themselves. The residents said they don't…

    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 · E2024-07-10 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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 effectively act upon repeated concerns from the facility's Resident Council and one resident (Resident #28) of 28 residents reviewed, resulting in resident frustration and anger that their concerns were not being addressed for 1) Call lights not being answered, 2) Food preferences and cold food, 3) The inability to entertain on the outdoor patio and 4) Removal of the Bingo store. Findings Include: FACILITY Resident Council On 7/09/24 at 2:03 PM, during a meeting with 18 members of the Resident Council, they said they were upset because their concerns were not being addressed. They said they bring their issues and concerns to the Resident Council meetings each month, but they do not feel anyone is listening or trying to resolve their issues. A review of the Resident Council meeting minutes, approved for review by the Resident Council President, identified the following: January 30, 2024 with 18 residents in attendance: Residents voiced they would like a staff member to stay with them on the independent side 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 · Dcited before2024-07-10 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 develop a baseline care plan for falls for one resident (Resident #24) of 28 residents reviewed for baseline care plans resulting in an incomplete baseline care plan and the resident sustaining falls. Findings include: Resident #24 (R24): Resident #24 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include epilepsy, depression and profound intellectual disabilities. On 07/08/24 at 01:16 PM, record review of the 802 revealed that R24 triggered on the report for falls in the facility. On 07/09/24 at 12:23 PM, record review revealed R24 had sustained falls on 05/22/24 and 07/04/24. On 07/09/24 at 12:27 PM, record review revealed R24 had a baseline care plan for falls that was dated 05/17/24, R24 was admitted to the facility on [DATE]. Record review revealed that R24 was assessed for fall risk on 05/14/24 and was a high risk for falls with a score of 22, anything higher than a score of 16 is high risk. A baseline care plan for…

    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 13 citations
  • Potential for harm · D2024-07-10 · 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 develop and implement a resident-centered comprehensive care plan for one resident (Resident #134) of 28 residents reviewed for Care Plans, resulting in Resident #134 lacking a Care Plan with resident-specific interventions to address likes and dislikes. Findings Include: Resident #134: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #134 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, urinary retention, glaucoma, anxiety, depression, pain, restlessness and agitation, constipation kidney cyst, neuralgia and a history of migraines. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 3/15 and was independent with ambulation needing supervision and supervision to assist with all care. On 7/08/24 at 3:29 PM, Resident #134 was observed wandering non-stop in the hallways and trying to go into…

    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 · D2024-07-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 update a care plan timely for one resident (Resident #24) of 28 residents reviewed for care plan updating resulting in late care plan revision after a fall. Findings include: Resident #24: Resident #24 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include epilepsy, depression and profound intellectual disabilities. On 07/08/24 at 01:16 PM, record review of the 802 revealed that R24 triggered on the report for falls in the facility. On 07/09/24 at 12:23 PM, record review revealed R24 had sustained falls on 05/22/24 and 07/04/24. On 05/22/24 R24 sustained an observed fall, R24 rolled out of bed during morning care, no injuries were noted, the physician and guardian were notified. The Certified Nursing Assistant (CNA) was in the room providing care to the roommate when R24 was noted to roll out of bed . New intervention was to place a perimeter mattress on the bed for a tactile barrier. Fall follow up completed.…

    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 · D2024-07-10 · 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 observation, interview and record review, the facility failed to prevent the development of a facility-acquired pressure injury and ensure timely nutritional evaluation with the development of the pressure injury for one resident (Resident #46) of three residents reviewed for pressure ulcers, resulting in a deep tissue injury to Resident #46's right heel, and the potential for lack of nutritional intervention to hasten the healing of pressure injury, and the potential of pain and discomfort. Findings include: Resident #46: A review of Resident #46's medical record revealed an admission into the facility on 2/28/20 with diagnoses that included heart disease, dementia, mental disorder, heart disease, diabetes and diabetic neuropathy. A review of the Minimum Data Set assessment revealed the Resident had a Brief Interview of Mental Status score of 2/15 that indicated severely impaired cognition and the Resident used a wheelchair, propelled wheelchair independently, was dependent with putting on/taking off…

    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 · Dcited before2024-07-10 · 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 observation, interview and record review, the facility failed to ensure that Resident #58 had oxygen available in the portable oxygen tank; properly store distilled water for a CPAP machine for a resident in room [ROOM NUMBER]-2; and remove/clean a CPAP machine for Resident #70, of four residents reviewed for respiratory care, resulting in the potential for infection, respiratory illness, low oxygenation, and shortness of breath. Findings include: Resident #58: A review of Resident #58's medical record revealed an admission into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, heart disease, and anxiety disorder. A review of the Minimum Data Set (MDS) assessment revealed the Resident had moderately impaired cognition and needed moderate assistance with bathing, upper body dressing, and toileting. A review of Resident #58 revealed an order for oxygen, Apply oxygen (per nasal cannula) to maintain O2 sat > or equal to 90%, dated 1/22/23. The document received from…

    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 · D2024-07-10 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 follow standards of practice for laboratory testing and antibiotic use for one resident (Resident #25) of 4 residents reviewed for antibiotic use, resulting in Resident #25 receiving antibiotic treatment without appropriate laboratory tests to determine if the resident had a urinary tract infection and if the antibiotic was appropriate. Findings Include: Resident #25: Urinary Catheter or UTI A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #25 indicated admission to the facility on 4/24/2020 with diagnoses: Alzheimer's dementia, diabetes, depression, peripheral vascular disease, heart disease, hypertension and a history of urinary tract infection/UTI. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss and needed assistance with all care. On 7/08/24 at 11:31 AM, during a tour of the facility, Resident #25 was observed sitting in a chair in her room. She was confused and didn't answer…

    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 · D2024-07-10 · 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 provide one resident (Resident #74) their 2023/2024 influenza vaccine, resulting in the likelihood of influenza contraction, hospitalization and/or death. Findings include: Resident #74: On 7/10/24, at 11:00 AM, a record review of Resident #74's immunizations revealed no influenza vaccine administration documentation. The facility was asked to provide proof of influenza vaccine documentation. A record review of Resident #74's Immunization Consent Form revealed Resident #74 gave permission for Influenza with their signature and a date of 5-13-24. On 7/10/24, at 2:27 PM, the DON offered that Resident #74 admitted with a gastrointestinal infection and was on antibiotics on and off. The DON offered that Resident #74 wasn't healthy enough to get the flu vaccine and then once they were it was passed the window to get the flu vaccine. On 7/10/24, at 3:35 PM, a record review along with the DON and the IC Nurse C of Resident 74's immunization list revealed that they received VACCINE ADMINSTERED . Sars-CoV-2 (Moderna Booster)…

    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 · D2023-06-30 · tag F0577 — isolated
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 inform and/or educate 6 out of 6 Residents who attended the Confidential Group Meeting about the location of the survey book and ensure that results from the most recent State Survey for complaint investigations and Plans of Correction (POC) for the preceding Standard Recertification Survey were readily accessible, affecting all 78 Residents residing in the facility, resulting in Residents, Residents' Representatives, families and visitors being unable to review the survey results and Plans of Correction. Findings include: On 6/29/23 at 11:01 AM, a meeting was held with a group of fifteen Residents in a confidential group meeting. The group was asked if the results of the State inspections were available to read. The group responded that they were not aware there was a binder or that survey results were to be available. The group did not know where the book would be found to read. On 6/29/23 at 2:25 PM, an observation was made of a binder located on a wall holder near the elevator for the 3rd floor. The book…

    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 · D2023-06-30 · 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

    Based on observation, interview and record review, the facility failed to ensure that neurological assessments (neuro checks) were completed per Standards of Practice, after unwitnessed resident falls and/or witnessed falls with head injury, for 3 residents (Resident #59, Resident #71, Resident #77) of 5 residents reviewed for falls, resulting in the potential for head injury without necessary neurological assessments that could further lead to serious complications and death. Findings Include: A facility policy identified the following: Neurological Assessment, date implemented 02/02/2004 and reviewed/revised 08/2022, . Neurological Assessment is to be performed by the licensed nurse when a resident's condition indicates that neurological changes are probable . Neurological assessment is also mandatory to perform following head trauma sustained during an accident and/or fall . Resident having an unobserved fall, observed fall with head involvement or accident involving know or suspected head injury are to have a neurological assessment completed by the licensed nurse immediately…

    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 · Dcited before2023-06-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 assess and monitor a urinary catheter for one resident (Resident #32), resulting in an unsanitary self-emptying urinary drainage bag and unkept urinary output logs. Findings include. On 6/29/23, at 2:33 PM, Certified Nursing Assistant (CNA) G was interviewed regarding Resident #32's urinary catheter output documentation. CNA G stated, that he self-empties it so they often chart zero. On 6/29/23, at 2:40 PM, an observation of Resident #32 along with CNA G was conducted of how Resident #32 self-empties their catheter bag. CNA G motioned to Resident #32 to go to the bathroom and empty their bag. CNA G stood next to Resident #32 in the bathroom. Resident #32 stood over the toilet which had a raised toilet seat, opened the end of the bag and drained the urine directly into the toilet. Resident #32 flicked the end of the bag almost hitting the toilet seat. CNA G was asked if Resident #32's roommate used the toilet and CNA G stated, yes. CNA G…

    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 · D2023-06-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that interventions were enacted to promote nutrition and prevent weight loss for one resident (Resident # 59) of 3 residents reviewed for food or nutrition, resulting in Resident #59 lacking timely assistance with meals, and interventions to prevent weight loss which lead to further weight loss. Findings Include: Resident #59: Nutrition: On 6/27/2023 at 12:25 PM, during lunch observation in the 3rd floor dining room, Resident #59 was observed sitting at a table in the dining room that was not served until last. The residents at the table were watching other residents eat around them. A staff member approached the table and said to the residents that she did not know the meal tickets hadn't been picked up. She took four meal tickets, but there were only three residents still sitting at the table, as Resident #59 was taken back to her room by a staff member. The staff member who took the tickets came back to the table with 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-30 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 that licensed nurses [Registered Nurses (RN) and Licensed Practical Nurses (LPN)] received yearly training competencies to ensure resident care and safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of residents for three nurses of five nurses reviewed for competencies, with the potential to affect all 78 residents residing in the facility, resulting in the potential of nursing staff lacking necessary training and competencies to adequately care for the needs of the residents residing in the facility. Findings include: On 6/30/23 at 11:07 AM, an interview was conducted with the Staff Development Coordinator, Nurse B regarding Nurse Competencies. The Nurse was asked about staff competencies and the Nurse reported that the facility holds a workshop with stations set up and the staff would go through the stations for their competencies with return demonstrations by the staff. The Nurse reported that the CNA's had completed their competencies in the beginning of June. 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 that drug regimen reviews were completed, dated and in the medical record monthly, for two residents (Resident #8 and Resident #20) of five residents reviewed for medications, resulting in the potential for each resident to receive unnecessary medications and develop adverse effects. Findings Include: Resident #8: A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #8 indicated the resident was admitted to the facility on [DATE] with diagnoses: Alzheimer's, Parkinson's, diabetes, depression, and anemia. The MDS assessment dated [DATE] revealed the resident had mild cognitive decline and needed some help with Activities of Daily Living (ADL). On 6/29/2023 at 1:24 PM, a record review of the medications for Resident #8 revealed the resident received 20 medications daily including the psychotropics: Cymbalta, Buspirone, Ativan, and Zyprexa. The resident also received narcotic medications and insulin. A record review…

    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 · D2023-06-30 · tag F0882 — isolated
    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 that the Infection Preventionist had completed the required training in Infection Prevention and Control. This deficient practice resulted in the potential for a lack of knowledge and appropriate response to aid in the prevention of infections that could lead to resident illnesses, outbreaks and possibly death. Findings Include: Infection Control: On 6/29/23 at 1:54 PM , the Infection Prevention and Control Nurse L was interviewed during a review of the Infection Prevention and Control program. The IPC Nurse was asked how long she had been working in the role of the IPC at the facility and she stated, Since October (2022). The IPC was asked what training she had for the role of IPC and she said she had not yet finished a training program. She said she was working on the CDC training program for Infection Prevention and Control in Long Term Care. The Infection Preventionist was asked why it was not yet completed, as she had been in the role for 8 months, and stated, I know I should have it done. I will get it done.…

    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

“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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
HURON COUNTY BUILDING OFFICE OF TREASUREROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 08/22/2005
LEGATZ, HEATHERIndividualMANAGING CONTROL - GOVERNING BODYsince 11/01/2017
MCDONALD, BETHIndividualMANAGING CONTROL - GOVERNING BODYsince 10/01/2024
ROLAND, JAMESIndividualMANAGING CONTROL - GOVERNING BODYsince 06/23/2021
KHAN, ALIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
KREBS, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/31/2025
LOCKARD, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$12.3M
Net patient revenuemost recent cost report
-16.8%
Operating marginrevenue minus expenses
$1.3M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 5%Other / private 11%

About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M 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

$484per resident / day
operating cost
$14,701per month
≈ monthly operating cost
$414per 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 235028. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-17, 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.

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