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The Oaks at Battle Creek

706 North Avenue, Battle Creek, MI 49017 · For profit - Corporation · 77 certified beds · (269) 964-4655 Medicare & Medicaid certified

Call the home — (269) 964-4655 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2026Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
710 North Ave · (269) 969-6251 · Call to confirm hours
Pharmacy
605 North Ave · (269) 660-1198 · Call to confirm hours
Grocery
250 Roosevelt Ave E · (269) 660-8544 · Call to confirm hours
Park
Kolb Park0.3 mi
Kolb Park · Typically dawn to dusk
Place of worship
620 N Washington Ave · (269) 965-2017

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 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 held steady at 4 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 rating4★
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 increased7.9%10.8%15.4%better
Long-stay residents who lose too much weight5.9%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.6%1.5%2.0%better
Long-stay residents with depressive symptoms2.3%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 injury0.5%3.0%3.3%better
Long-stay residents whose ability to walk worsened8.1%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.9%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine96.3%95.0%95.3%typical
Long-stay residents with pressure ulcers1.0%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control24.8%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table6.3%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine97.6%79.5%79.4%better
Short-stay residents rehospitalized after admission27.0%24.0%22.6%worse
Short-stay residents with an outpatient ER visit15.0%11.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.191.841.67worse
Long-stay outpatient ER visits per 1,000 resident days0.961.641.80better

§ 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.

58.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 291 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.7%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
72.3%U.S. median 56.6%
Met the expected recovery
0.52U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 72.3% 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 137 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 SNF58.7%CMS range 53.7–62.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 8.3–13.410.7%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 discharge72.3%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 discharge65.7%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 discharge56.9%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 identified100.0%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.2%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 worsened0.5%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 hospitalization9.3%CMS range 5.8–12.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 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

0.99
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.43
Aide hours/ resident / day
4.17
Total nurse hours/ resident / day
0.82
RN hoursweekends
23.1%
Total nursing turnover
7.7%
RN turnover

How full it usually is: this home is certified for 77 beds and averages 68.9 residents a day — about 89% occupied, or roughly 8 beds typically open. It runs fairly full. 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 4.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.99 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 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 3.93 hrs/resident/day on weekends vs 4.27 on weekdays — 8% thinner on weekends. RN hours go from 1.05 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% is below 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

9
deficiencies at the latest standard inspection (2025-03-12)
2
at the previous standard inspection (2024-04-18)

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.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · D2026-06-05 · 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

    This citation pertains to Intakes: 2790134Based on observation, interview, and record review the facility failed to provide an environment free from physical and verbal abuse for two Residents (#29, #95) of two residents reviewed for abuseFindings Included:Resident #29 (R29)Review of the medical record revealed R29 was admitted to the facility 01/02/2025 with diagnoses that included kidney disease, type 2 diabetes, morbid obesity, hyperlipidemia (high fat concentration in blood), depression, anxiety, chronic pain, tachycardia, and heart disease. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed R29 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.Resident #95 (R95)Review of the medical record revealed R95 was admitted to the facility 08/12/2025 with diagnoses that included kidney disease, type 2 diabetes, atrial fibrillation, dysphagia (difficulty swallowing), dementia, muscle weakness, anemia (low red blood cell count), osteoarthritis (degenerative joint disease), hypothyroidism (low thyroid…

    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 plan of correction
  • Potential for harm · F2025-03-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 food was served and held at a palpable temperature. Resulting in the potential to affect all residents (total facility census of 70) that consume food from the kitchen. Findings Included: Resident #173 (R173) Review of the medical record revealed R173 was admitted to the facility 02/14/2025 with diagnoses that included prosthetic left hip joint, fracture of left femoral neck, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), depression, anemia (low red blood cells), osteoarthritis (type of arthritis occurs when tissue at end of bones wears down), unilateral inguinal hernia, and pain in left hip. The Minimum Data Set, with an Assessment Reference Date (ARD) of 02/20/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment) out of 15. During observation and interview on 03/10/2025 R173 was observed lying down in bed. R173 explained that five out of seven days the food was cold. R173 explained that the food that should have been hot 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-12 · 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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 70 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and plumbing water leaks. Findings include: On 03/10/25 at 07:35 A.M., An initial tour of the food service was conducted with Dietary [NAME] C. The following items were noted: 1 of 2 True 2-door reach-in cooler doors were observed to not automatically close completely after opening, creating an air gap (approximately 1-2-inches wide between the refrigeration unit frame and the door gasket seal). The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal…

    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 · E2025-03-12 · 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 practice effective infection prevention standards related to hand hygiene, 1) adhere to infection control practices, during medication administration with three of four nurses; and 2) facility failed to maintain infection control practices, in one of two wounds, Resident #59 (R59). Findings Included: Resident #59 (R59) Review of the medical record reflected R59 was an initial admission to the facility on [DATE]. Diagnoses of Congested Heart Disease, Chronic Kidney Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease and Diabetes. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2024, revealed R59 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section GG0100, Activities of Daily Living (ADL) Assistance reveals R59 requires set up/moderate assist with all care. During an interview and observation on 03/12/25 at 9:37 AM of Wound 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 · D2025-03-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to advocate for one out of two residents (#29) reviewed for dignity resulting in the resident feeling unheard, decreased self-worth, frustration, decreased quality of life and suffered mental anguish. Findings include: Resident #29 (R29) Review of the medical record reflected R29 was an initial admission to the facility on [DATE]. Diagnoses of Aphasia following cerebral infarction, anxiety, nontraumatic intracerebral hemorrhage in hemisphere, speech and language deficits following cerebral infarction, Dysarthria, Dysphagia, needs assistance with personal care, Chronic Obstructive Pulmonary Disease and unsteady gait. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2024, revealed R29 had a Brief Interview of Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. During an interview on 03/10/25 at 10:30 AM, anonymous interviewee T stated they had concerns regarding a resident that was 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-12 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 Notice of Medicare Non-Coverage (NOMNC) was provided for two Residents (#2 and #179) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided for three Residents (#2, #178, and #179) out of three reviewed for Beneficiary Notification. Findings Included: Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 10/02/2024 with diagnoses that included chronic kidney disease, hyponatremia (low sodium level) type 2 diabetes, atrial fibrillation, chronic obstructive pulmonary disease (COPD), anemia (low red blood cells), hyperlipidemia (high fat content in blood), depression, chronic pain, and gastro-esophageal reflux disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 01/06/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. In an interview on 03/12/2025 at 10:25 a.m. Licensed Nursing Home Administrator (LNHA) A explained that she could not verify that R2 had a Notice 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 · D2025-03-12 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 resident medical records were secured and held confidential for 1 resident (R8) of 17 residents sampled, resulting in exposed resident medical information. Findings include: On 3/10/25 at 7:55 AM, the medication cart was observed in the hallway outside of R8's room, with the computer screen open with R8's profile in focus and visible for anyone that walked in the hallway. No nurse was present at that time. LPN E returned to the cart, when asked if she would normally lock her computer screen when she walks away she reported that the screen normally locks on it's own after three seconds. On 3/10/25 at 7:58 AM, LPN E was observed walking away from the medication cart for a second time without locking the computer screen, leaving resident information exposed. LPN E was observed walking into and out of two resident's rooms before returning to the medication cart. On 3/10/25 at 8:01 AM, LPN E was observed walking away from the medication cart for a third time, without locking the computer screen. LPN E walked…

    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 · D2025-03-12 · 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 person centered care plan for targeted behaviors for the use of psychotropic medications for one Resident (Resident 20) of 17 residents reviewed for care plans. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 20 (R20) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, unspecified dementia with psychotic disturbance and depression and was admitted on an anti-psychotic medication. R20 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview Mental (BIMS). The mood and behavior section of the MDS revealed R20 had no mood, behavior concerns and no hallucinations or delusions. The 11/20/24 MDS reflected R20 had no mood problems, no hallucinations, no delusions and wandered 1 to 3 days a week. R20 was observed throughout the survey R20 was well groomed, smiling and engaged with peers…

    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 · D2025-03-12 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 meaningful activities were provided for one resident (R26) out of two resident who are dependent on staff for transferring and mobility and the likelihood for depression, feelings of melancholy using the reasonable person concept. This deficient practice resulted in the potential for boredom, lack of stimulation and loneliness. Findings Include: Resident #26 (R26) Review of the medical record reflected R26 was an initial admission to the facility on [DATE]. Diagnoses of a Stroke, Hypertension, Coronary Artery Disease, Hemiplegia on right side, Malnutrition, Depression and Anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2024, revealed R26 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section GG0100, Activities of Daily Living (ADL) Assistance reveals R26 requires minimal/moderate assist with all care and minimal assist setting up 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 residents prescribed anti-psychotic medication had an adequate indication for use, clinical rational to support continued use, as well as identify and monitor resident specific specific behaviors and approaches and non-pharmacological approaches for one resident (Resident #20) of five residents reviewed for unnecessary medications. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 20 (R20) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, unspecified dementia with psychotic disturbance and depression and was admitted on an anti-psychotic medication. R20 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview Mental (BIMS). The mood and behavior section of the MDS revealed R20 had no mood, behavior concerns and no hallucinations or delusions. The 11/20/24 MDS reflected R20 had no mood problems, no…

    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
Show the remaining 11 citations
  • Potential for harm · Fcited before2024-04-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 68 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 04/16/24 at 09:30 A.M., An initial tour of the food service was conducted with Dietary Manager Q. The following items were noted: The Pitco fryer interior and adjacent flooring/wall surfaces were observed soiled with accumulated and encrusted grease/dirt deposits. Dietary Manager Q indicated he would have staff thoroughly clean and sanitize the fryer interior and adjacent flooring/wall surfaces as soon as possible. The Panasonic microwave oven interior was observed (etched, scored, particulate). The damaged interior surface measured approximately 5-inches-wide by 5-inches-long. The interior door panel face was also observed (etched, scored, particulate), exposing the metal subsurface. The damaged interior door panel face measured approximately…

    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 · D2024-04-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to one Resident (# 48) of one resident reviewed for Hospice services, resulting in the lack of coordination of comprehensive services and care provided. Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident 48 (R48) was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included dementia. R48 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), further review of the clinical record reflected R48 was receiving hospice care as of 9/12/23. On 04/17/24 at 12:46 PM, Licensed Practical Nurse (LPN) P reported the Nursing staff were not informed about hospice schedules and do not have any type of schedule or calendar to refer to. We just know it will be twice a week. LPN P further stated when the hospice nurse comes weekly they then inform the facility 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-19 · tag F0564 — isolated
    Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
    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 MI000139094. Based on interview and record review the facility failed to ensure resident rights in accordance to preferences were followed for one out of three residents (Resident #1), resulting in restrictions of a visitor, and the potential for further resident preferences to not be followed. Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. R1 no longer resided at the facility at the time of the onsite investigation. In an interview on 9/18/2023 at 9:32 AM, R1's wife stated that when R1 was being admitted to the facility she told a staff member (could not recall who) that she wanted to stay the night with R1. R1's wife said she was told no she could not stay the night with R1. In an interview on 9/18/2023 at 1:06 PM, Guest Relations and Admissions staff member (GRA) C stated R1's wife arrived at the facility before R1 had, but stated R1 was in route. GRA C said she introduced herself to R1's wife, and stated that she did…

    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 before2023-01-25 · 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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 67 residents, resulting in the increased likelihood for cross-contamination, and bacterial harborage. Findings include: During an initial kitchen tour on 1/23/23 at 9:28 AM, Kitchen Manager (KM) X reported was working as cook that day. Observed the three-compartment sink filled and KM X reported had just been filled and tested. This surveyor requested KM X to demonstrate test and was unable to obtain reading from guat test strip. Observed test strips with expiration date of 10/2022. At 9:47 AM KM X attempted to test with chlorine test strips blue and reported was unsure why was not working. KM X obtained quat strips after communication by text and reported would record at 150 ppm (parts per million). Record review of the kitchen log including the three compartment sink revealed several blank (missing) documentation noted and the three-compartment sink documentation reflected reading of 400 for all of January(out of range for quat test strips.…

    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 · E2023-01-25 · 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 interview and record review the facility failed to ensure resident council complaints were followed-up with a response for a resolution from the appropriate department, resulting in the potential for resident frustration and needs not being met. Findings included: On 1/24/2023 at 1:14 PM, during a confidential resident group meeting, two out of five residents stated that a male resident would frequently enter their rooms and take their belongings. Record review of Resident Council Meeting Minutes dated 11/15/2022, revealed, under Social Services, documentation that residents had complained about a male resident who wandered into their rooms. Review of a Resident Council Response form dated 11/15/2022, revealed Social Services did not address resident complaints regarding a male resident who wandered into their rooms. Record review of Resident Council Meeting Minutes dated 1/19/2023, revealed, under Social Services, residents had the same complaint regarding a male resident wandering into their rooms, putting his hands on their personal items, and taking other resident's…

    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 · E2023-01-25 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 observations, interviews, and record reviews, the facility failed to effectively maintain comfortable hot water temperatures effecting three residents (R5, R13, and R16) and 200 hall residents, resulting in the increased likelihood for resident discomfort, poor hygiene and frustration. Findings include: Resident #5(R5) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R5 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), heart failure, renal failure, anxiety, and depression. The MDS reflected R5 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required two person physical assist with bed mobility, transfers, dressing and one person physical assist with locomotion on unit, hygiene, and bathing. During an observation and interview on 1/23/23 at 12:09 PM R5 was laying in bed and able to answer questions appropriately. R5 reported…

    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 · E2023-01-25 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 grievances were investigated, and resolved for four Residents (R4, R5, R13, and R49) and failed to implement facility grievance policy, resulting in feelings of anger, frustration and feelings of not being heard. Findings include: Resident #5(R5) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R5 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), heart failure, renal failure, anxiety, and depression. The MDS reflected R5 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required two person physical assist with bed mobility, transfers, dressing and one person physical assist with locomotion on unit, hygiene, and bathing. During an observation and interview on 1/23/23 at 12:09 PM R5 was laying in bed and able to answer questions appropriately. R5…

    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 · D2023-01-25 · 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 observation, interview, and record review, the facility failed to ensure updated and accurate advance directive information was in place for one residents (Resident #5) of two reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years 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 · D2023-01-25 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 provide scheduled showers twice per week for 1 resident (#4) of 5 residents sampled for activities of daily living (ADLS) resulting in resident personal care needs not being met. Resident #4 (R4) Review of the medical record revealed R4 was admitted to the facility 12/16/2021 with diagnoses that include moderate protein-calorie malnutrition, hypothyroidism (low thyroid hormone), diabetes, front temporal neurocognitive disorder, tricuspid valve insufficiency, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, pulmonary hypertension (high blood pressure), anxiety, depression, essential tremors (rhythmic shaking), irritable bowel syndrome (IBS), rectal prolapse, insomnia, allergic rhinitis (seasonal allergies), cognitive impairment, tachycardia, oral dysphagia (problem using mouth, lips, and tongue to control food and liquids), cognitive communication deficit, diverticulosis (inflammation of digestive tract), hypoxemia (low level of oxygen in blood), suicidal ideations, gastro-esophageal…

    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 · D2023-01-25 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 properly assess and identify the need for podiatry services for one resident (Resident #5) reviewed for foot care, resulting in resident frustration, the development of long toenails, pain and delay in needed treatment. Findings include: Resident #5(R5) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R5 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), heart failure, renal failure, anxiety, and depression. The MDS reflected R5 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required two person physical assist with bed mobility, transfers, dressing and one person physical assist with locomotion on unit, hygiene, and bathing. During an observation and interview on 1/23/23 at 12:09 PM R5 was laying in bed and able to answer questions appropriately. R5 reported…

    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 · D2023-01-25 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    During observation, interview, and record review the facility failed to provide food preferences for two Residents (#4 and #49) of 17 sample Residents resulting in not honoring food preferences and resulting in the potential frustration of residents and a non-pleasurable dining experience. Findings Include: Resident #4 (R4) Review of the medical record revealed R4 was admitted to the facility 12/16/2021 with diagnoses that include moderate protein-calorie malnutrition, hypothyroidism (low thyroid hormone), diabetes, front temporal neurocognitive disorder, tricuspid valve insufficiency, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, pulmonary hypertension (high blood pressure), anxiety, depression, essential tremors (rhythmic shaking), irritable bowel syndrome (IBS), rectal prolapse, insomnia, allergic rhinitis (seasonal allergies), cognitive impairment, tachycardia, oral dysphagia (problem using mouth, lips, and tongue to control food and liquids), cognitive communication deficit, diverticulosis (inflammation of digestive tract), hypoxemia (low level 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.

    Nutrition and Dietary 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.

Part of a chain

This home belongs to TRILOGY HEALTH SERVICES — 123 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 4 of 54.2-0.2 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 122 homes this chain runs (chain average 4.2★, per CMS)
1 of 5Heritage TheFindlay, OH 1 of 5The Oaks Rehabilitation and Healthcare CenterZanesville, OH 2 of 5Homewood Health CampusLebanon, IN 2 of 5Violet Springs Health CampusPickerington, OH 2 of 5Woodmont Health CampusBoonville, IN 3 of 5Cobblestone Crossings Health CampusTerre Haute, IN 3 of 5Creasy Springs Health CampusLafayette, IN 3 of 5Cumberland Pointe Health CampusWest Lafayette, IN 3 of 5Forest Park Health CampusRichmond, IN 3 of 5Franciscan Health Care CenterLouisville, KY 3 of 5Greenleaf Health CampusElkhart, IN 3 of 5River Terrace Health CampusMadison, IN 3 of 5Scenic Hills At The MonasteryFerdinand, IN 3 of 5Smiths Mill Health CampusNew Albany, OH 3 of 5Springhurst Health CampusGreenfield, IN 3 of 5Springs Of Richmond, TheRichmond, IN 3 of 5St Mary Healthcare CenterLafayette, IN 3 of 5Stonegate Health CampusLapeer, MI 3 of 5Sun Prairie Senior LivingSun Prairie, WI 3 of 5Taylor Springs Health CampusGahanna, OH 3 of 5The Willows at Fritz FarmLexington, KY 3 of 5The Willows at HamburgLexington, KY 3 of 5The Willows at HarrodsburgHarrodsburg, KY 3 of 5The Willows at SpringhurstLouisville, KY 3 of 5Villages At Oak Ridge, TheWashington, IN 3 of 5Waunakee Valley Senior LivingWaunakee, WI 3 of 5Wellbrooke Of CarmelCarmel, IN 4 of 5Arlington Place Health CampusIndianapolis, IN 4 of 5Ashford Place Health CampusShelbyville, IN 4 of 5Aspen Place Health CampusGreensburg, IN 4 of 5Avalon Springs Health CampusValparaiso, IN 4 of 5Bethany Pointe Health CampusAnderson, IN 4 of 5Blair Ridge Health CampusPeru, IN 4 of 5Bridgepointe Health CampusVincennes, IN 4 of 5Cedar Creek Health CampusLowell, IN 4 of 5Clearvista Lake Health CampusIndianapolis, IN 4 of 5Forest Springs Health CampusLouisville, KY 4 of 5Glen Oaks Health CampusNew Castle, IN 4 of 5Glen Ridge Health CampusLouisville, KY 4 of 5Meadows Of Delphos TheDelphos, OH

Showing 40 of 122; lowest-rated first.

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

Investor-owned

CMS ownership filings flag an owner of this facility as a private-equity firm and a real-estate investment trust (REIT). That’s a fact worth knowing: peer-reviewed research links private-equity and REIT ownership to lower staffing and more citations on average — though any individual home can run well or poorly regardless. Read the inspection and staffing record above on its own merits.

  • AMERICAN HEALTHCARE REIT INC — REIT · 100.00% share · 5% Or Greater Indirect Ownership Interest
  • TRILOGY REAL ESTATE INVESTMENT TRUST — REIT · 97.40% share · 5% Or Greater Indirect Ownership Interest
  • GAHC3 TRILOGY JV LLC — private equity · 70.00% share · 5% Or Greater Indirect Ownership Interest
  • TRILOGY OPCO LLC — private equity · 100.00% share · 5% Or Greater Direct Ownership Interest
  • TRILOGY HOLDINGS NT-HCI, LLC — private equity · 24.00% share · 5% Or Greater Indirect Ownership Interest
  • TRILOGY INVESTORS LLC — private equity · 100.00% share · 5% Or Greater Indirect Ownership Interest
  • TRILOGY HEALTHCARE HOLDINGS INC — private equity · 100.00% share · 5% Or Greater Indirect Ownership Interest
  • CONTINENTAL MERGER SUB LLC — private equity · 100.00% share · 5% Or Greater Indirect Ownership Interest

Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →

Owner / managerTypeRoleShareSince
CONTINENTAL MERGER SUB LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
NORTHSTAR HEALTHCARE INCOME INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
NORTHSTAR HEALTHCARE INCOME OPERATING PARTNERSHIP LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
TRILOGY HOLDINGS NT-HCI, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
KEYBANK NATIONAL ASSOCIATIONOrganization5% OR GREATER MORTGAGE INTERESTsince 05/01/2016
CORBIN, KATHYIndividualW-2 MANAGING EMPLOYEEsince 01/11/2011
FIGHTMASTER, LISAIndividualW-2 MANAGING EMPLOYEEsince 12/01/2015
WILLHITE, GABRIELIndividualCORPORATE DIRECTORsince 08/15/2023
BARNEY, LEIGHIndividualCORPORATE OFFICERsince 11/01/2019
CONNER, GREGORYIndividualCORPORATE OFFICERsince 06/03/2021
DAVIS, DAVIDIndividualCORPORATE OFFICERsince 08/21/2017
MEHAFFEY, TODDIndividualCORPORATE OFFICERsince 01/31/2022
PIETROWSKI, CRISTINAIndividualCORPORATE OFFICERsince 01/31/2022
PROSKY, DANNYIndividualCORPORATE OFFICERsince 12/01/2015
TRILOGY MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2021
SMITH, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2021

6 organizational owners 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.

$11.6M
Net patient revenuemost recent cost report
+3.7%
Operating marginrevenue minus expenses
$1.5M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 17%Other / private 41%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$380per resident / day
operating cost
$11,562per month
≈ monthly operating cost
$395per 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 235451. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-12, 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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