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Caretel Inns of Brighton

1014 E Grand River, Brighton, MI 48116 · For profit - Corporation · 60 certified beds · (810) 220-5222 Medicare & Medicaid certified

Call the home — (810) 220-5222 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 20232 actual-harm citations
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2023
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (68%) runs well above the national median (45%)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 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

Urgent care / clinic
1036 E Grand River Ave · (810) 227-1540 · Call to confirm hours
Pharmacy
123 Brighton Lake Rd Ste 202 · (810) 224-7506 · Call to confirm hours
Grocery
9870 E Grand River Ave · (810) 229-0317 · Call to confirm hours
Park
800 W Grand River Ave · (810) 494-7100 · Typically dawn to dusk
Place of worship

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 3 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 fell from 4 to 3 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 rating3★
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 increased5.7%10.8%15.4%better
Long-stay residents who lose too much weight0.0%5.4%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection2.8%1.5%2.0%worse
Long-stay residents with depressive symptoms12.2%4.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury10.3%3.0%3.3%worse
Long-stay residents on antianxiety or hypnotic medication16.1%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers9.6%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control32.3%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.8%14.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.2%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine99.7%79.5%79.4%better
Short-stay residents rehospitalized after admission20.6%24.0%22.6%typical
Short-stay residents with an outpatient ER visit9.0%11.7%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

63.9% 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 461 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.9%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
66.5%U.S. median 56.6%
Met the expected recovery
0.76U.S. median 0.31
Therapy hours / resident / day
0.32hours / resident / day
Physical therapy
0.33hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 66.5% 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 185 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 0.76 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF63.9%CMS range 57.4–67.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 9.7–14.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.5%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 discharge67.0%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 discharge63.2%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 identified99.1%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 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 worsened3.6%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 hospitalization5.1%CMS range 3.4–8.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 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

0.92
RN hours/ resident / day
1.16
LPN hours/ resident / day
1.89
Aide hours/ resident / day
3.97
Total nurse hours/ resident / day
0.45
RN hoursweekends
68.1%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 56.7 residents a day — about 94% occupied, or roughly 3 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 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.92 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 3.31 hrs/resident/day on weekends vs 4.23 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.11 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2026-02-11)
7
at the previous standard inspection (2024-10-23)

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.

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

  • Actual harm · Gcited before2026-02-11 · 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 Stage 3 pressure injury for one Resident (R57) of one resident reviewed for pressure injuries, resulting in wound treatments, increased pain and discomfort, and the potential for further wound deterioration. Findings include: On 2/09/26 at 1:46 p.m., R57 was observed in their room in their hospital bed, lying on their left side, directly on the trochanteric (hip) area, with their legs bent at their knees. There was no offloading device behind them, including pillows or a wedge to support their back on their bed. No offloading devices were observed in their room. It was noted R57 was positioned on an air mattress. The bed had no footboard. On 2/09/26 at 1:47 p.m., R57 stated, You can see the bed does not fit my frame . R57 reported they had asked staff for a new bed as long as I have been here, and said staff did not get them one. R57 explained their legs were curled to stay on the bed. R57 said they laid on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-11-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake 2660312Based on interview and record review, the facility failed to implement a resident-centered intervention which required a two-person total assist for positioning onto a bedpan for one (R701) of one resident reviewed for falls, resulting in R701 falling to the floor, sustaining a left clavicle (collarbone) fracture, new pain and discomfort to their left upper extremity.Findings include:A concern was filed with the State Agency alleging on 9/18/25 prior to being transferred for their weekly outpatient paracentesis (procedure that involves the removal of fluid from the abdomen) appointment, two family members and two EMT's (Emergency Medical Technician) personnel were waiting outside R701's room while they (R701) were cared for by one Certified Nurse Assistant (CNA) to use the bedpan. While waiting, R701 was heard yelling I am going to fall, then a loud thump was heard and R701 was found lying on the floor.Clinical record review revealed R701 was admitted to the facility on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-02-11 · 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 best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 02/11/26 at 8:14 AM observation of the kitchen two door cooler found a package of opened hot dogs with a facility marked date of 1/21/26. An interview at this time with Dietary Manager (DM) F found they use a seven-day discard for ready-to-eat, time/temperature control for safety foods.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the needs of two Residents (R57 and R77) when appropriate durable medical equipment was not provided to accommodate their functional medical care needs. Findings include: R77 On 2/09/26 at 1:56 p.m., R77 was observed dressed, seated upright in their wheelchair in their room. On 2/09/26 at 1:58 p.m., R77 reported they had notified staff since yesterday (2/08/26) their toilet safety frame over their toilet was crooked and said, nothing was done. R77 explained they felt nervous using their toilet. R77 described they sometimes waited extended periods (30 or more minutes) for assistance with toileting needs, which made them feel scared, being seated on an uneven commode seat. On 2/09/26 at 2:01 p.m., R77's bathroom was observed. There was a toilet safety frame which was worn and rusted at the base of one commode leg, on the right rear side. This caster was about a 1-inch difference in height (higher) than the others, so it did 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 · D2026-02-11 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 #2677940Based on observation, interview and record review, the facility failed to ensure ancillary services were provided in a timely manner for three residents (R6, R20 and R64) of three residents reviewed for medically related Social Services. Findings include: R6 On 2/9/26 at approximately 11:03 AM, R6 was observed lying in bed. The resident was alert and able to answer questions asked. When queried as to the care provided by the facility, R6 reported that they needed follow up with their hearing aid and outside dental care. They also reported that they had been seen by an ophthalmologist that recommended they needed cataract surgery, and nothing had been scheduled. They further noted that they were supposed to see an outside dentist and something happened with transportation and the appointment was cancelled. They were not aware that it had been rescheduled. With respect to the hearing aid, they noted that they were seen last year and were told that they were getting a new…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 medication error rate of less than five percent when two medication errors were observed (R3, R79) from a total of 29 opportunities resulting in an error rate of six percent.On 2/10/26 at 7:51 AM, Licensed Practical Nurse (LPN) C was observed for medication administration. R3 was ordered Miralax (medication to treat irregular bowel movements and constipation)17 grams. LPN C was observed pouring the medication granules into the measuring cap and was asked how to confirm the measure was 17 grams. LPN C was observed pointing to the inside of the measuring cap and indicated the white thread halfway in the white part of the cap cup was 17 grams.On 2/10/26 at 8:18 AM, LPN D was observed for medication administration. R79 was ordered Aspirin 81 milligrams (mg) oral tablet delayed release. LPN D was observed preparing Aspirin 81 mg chewable and administered to R79.On 2/10/26 at 10:45 AM, The Director of Nursing (DON) was asked to demonstrate how nurses measure 17 grams of Miralax. The DON retrieved a bottle…

    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 · Dcited before2025-02-06 · 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 This citation relates to Intake #MI00149608. Based on interview and record review, the facility failed to provide dignified care to answer call lights timely for two Residents (R804, R806) of five residents reviewed for dignity. Findings include: On 2/05/25 at 12:08 p.m., R804 was observed seated in a manual wheelchair, dressed, with a full mechanical lift body sling underneath them. An air mattress was observed on their bed. R804 was asked if they had any pressure ulcers, and responded, Yes. R804 was frowning and appeared ready to cry. On 2/05/25 at 12:13 p.m., R804 reported they felt upset and angry as they were waiting too long for their call light to be answered. R804 explained they always waited at least 15 to 20 minutes and sometimes they waited for at least a half hour, including today. R804 stated, This morning I had an accident (incontinence episode). I am left wet and having to sit in it. This is happening all the time . R804 further clarified this occurred anytime during the day or night. R804 looked…

    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 before2025-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation relates to Intake #MI00149071. Based on observation, interview, and record review, the facility failed to demonstrate professional standards of care related to one Resident (R807) of one resident reviewed for quality of care, when they did not provide a wheelchair cushion for a resident at risk for skin breakdown, resulting in pain and the potential for skin breakdown. Findings include: On 2/05/25 at 2:59 p.m., R807 was observed in their room, seated in a manual wheelchair, and appeared thin and underweight. This Surveyor observed they had no wheelchair cushion underneath them. On 2/05/25 at approximately 3:04 p.m., R807 reported they were uncomfortable and their bottom was hurting when they sat in their wheelchair. R807's Family Member (FM) F, who was present, and R807 reported they had no wheelchair cushion in their wheelchair since their admission. FM F explained R807 was admitted about a week prior with a wound on their bottom, which was the size of a quarter currently. FM F stated R807 had…

    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 · Fcited before2024-10-23 · 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, sub kitchen, and dining room counter resulting in the potential to affect all residents that consume food from the kitchen, sub kitchen, and dining room counter. Findings include: On 10/21/24 at 9:17 AM, during an initial tour of the kitchen, the following items were observed with Dietary Director I (DD I): 1. Dried Food debris on the bottom of multiple refrigerators. 2.Food debris and frozen vegetables (peas) on bottom of the freezers. 3. Food debris on top of the stove and dried splattering on side of the stove. 4. Moderate amounts of debris around entire kitchen floor. 5. Floor mats soiled with food debris and sticky when stepped onto mat. On 10/22/24 at 8:00 AM, an observation of the sub kitchen during breakfast service was conducted and revealed: 1. Back sink next to dishwashers revealed under the sink, a Styrofoam cup, red straw, condiment papers and a white brush. 2. Ice machine grate and basin revealed dried brown splattered matter. 3. Juice dispensing…

    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 before2024-10-23 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview the facility failed to implement an active water management plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) resulting in the potential for water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among residents in the facility. Findings include: On 10/23/24 at 1:45 PM, the facility's Water Management binder was reviewed with the Nursing Home Administrator (NHA), Maintenance Director A, and Corporate Director of Facility Management G was present to provide oversite. When questioned what measures were taken to monitor the water, the facility acknowledged only a quarterly water temperature monitoring was performed. The process involved the water being brought up to 140 degrees from the boiler and then let it flow. When questioned what measures were taken for the facility and monitoring for Legionella, the facility stated chlorine residuals are not measured, and unable to provide documentation of water monitoring.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-23 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of spiders and drain (sewer) flies throughout the facility. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/21/24 at 11:00 AM, 3:00 PM and 10/22/24 at 8:45 AM and 1:30 PM, the 200 hallway was observed to have multiple areas of live spiders and webs on and around the hallway love seat, and there were multiple live drain flies observed on the walls, baseboards and more heavily at the base of a door that was locked and marked for employees only. There were multiple (eight) dead drain flies observed on the window ledge in the hallway across from room [ROOM NUMBER]. Review of the pest control logs provided by the facility revealed there were monthly visits with the most recent visit on 9/16/24 which identified only house mice pest type in the main building. The remaining main interior building identified No Activity…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-23 · 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 observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment, affecting multiple residents throughout the facility. Findings include: On 10/21/24 at 11:00 AM, 3:00 PM and 10/22/24 at 8:45 AM and 1:30 PM, the 200 hallway was observed to have multiple areas of live spiders and webs on and around the hallway love seat, and there were multiple live sewer flies observed on the walls, baseboards and more heavily at the base of a door that was locked and marked for employees only. There were multiple (eight) dead sewer flies observed on the window ledge in the hallway across from room [ROOM NUMBER]. On 10/22/24 at 2:30 PM, an interview was conducted with the Maintenance Director (Staff 'A') who reported they began to work at the facility on 4/24/24. They also reported they had recently taken over as the Housekeeping Manager in August. When asked about their housekeeping staff, Staff 'A' reported they were short three housekeepers and have a few…

    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
Show the remaining 17 citations
  • Potential for harm · Ecited before2024-10-23 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently ensure medications were properly secured and that expired medications were discarded. Findings include: On 10/21/2024 at 11:38 AM an oblong-shaped, white tablet was observed on the floor in a resident's room (visible upon entering the room, located near his bed). The tablet was observed to still be on the floor at 3:11 PM. At 4:39 PM. LPN J was shown the tablet and reported that they believed it was a Tylenol. LPN J reviewed the resident's medication record which showed the last documented dose was on 10/2/2024. The tablet had L484 imprinted on one side, which is consistent with a generic 500 mg (milligram) Tylenol. A review of the resident's orders revealed an order for Tylenol 325 mg. On 10/22/24 at 8:30 AM, the Director of Nursing (DON) was informed of the medication observed on the floor of R16's room. The DON reported that they had discussed this with the resident, who reported they had brought in the Extra Strength…

    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 · D2024-10-23 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one resident (R27) of one resident reviewed for PASARR (Preadmission Screen and Resident Review). Findings include: Clinical record review revealed R27 was admitted to the facility on [DATE] with heart disease, hypertension, and stroke. Psychiatric history included anxiety, depression and bipolar disorder. A Brief Interview for Mental Status (BIMS) evaluated on 8/17/24 score totaled 15/15 indicating R27 was cognitively intact. On 10/21/24 at 1:13 PM, a record review of the available PASSAR dated 11/11/23 revealed R27 was a Thirty Day-Hospital Exemption Discharge. There was no evidence a Level II evaluation was completed (given the resident's recent mental status exam which indicated intact cognition) R27 would likely require a Level II evaluation for a psychiatric history anxiety, depression and bipolar disorder. On 10/22/24 at 3:15 PM, an Interview with the Facility…

    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 · D2024-10-23 · 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 obtain physician orders for one resident (R32) of one reviewed for oxygen use, and not monitoring oxygen delivery equipment for proper fit, resulting in the potential for respiratory distress, and undetected respiratory status changes. Findings include: A clinical record review revealed R32 was admitted on [DATE] for skilled nursing and rehabilitation related to a fall at home and required left femoral hip surgery. Diagnoses included a stroke resulting in right sided weakness, hypertension, and COPD (Chronic Obstructive Pulmonary Disease). The Brief Interview of Mental Status (BIMS) score assessment on 10/2/24 was 5/10 indicating R32 had moderate cognitive impairment. On 10/21/24 at 10:13 AM, during initial introduction, R32 was observed lying in bed wearing a nasal cannula (medical device that delivers oxygen into the nostrils) incorrectly, observed only right nares receiving oxygen dispensing two liters of oxygen. On 10/21/24 at 10:40…

    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 · D2024-05-21 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00144321 and MI00144496. Based on interview and record review, the facility failed to notify the Licensed Practitioner and Resident Representative regarding an unwitnessed fall for one (R903) of two residents reviewed for accidents. Findings include: Review of complaints reported to the State Agency alleged R903 was found on the floor in the resident's room on 4/23/24 at 5:45 PM and the resident's representative was not informed of the fall, change in condition, and the need for additional pain medication related to right hip pain until 4/25/24 at 10:30 PM as the facility was preparing the resident for transfer to the emergency department. According to the facility's policy titled, Falls Management dated 3/2024: .If a fall occurs the following actions will be taken .RN/LPN (Registered Nurse/Licensed Practical Nurse) at time of fall occurrence .Notify the Licensed Practitioner and the Resident's Representative . Review of the clinical record revealed R903 was admitted into 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00144321 and MI00144496 Based on interview and record review, the facility failed to ensure timely and adequate assessment and investigation into an unwitnessed fall for one resident (R903)of two residents reviewed for falls, resulting in a delay of post-fall policy practices which included increased monitoring, initiate an investigation which delayed identification of an acute hip fracture resulting in transfer to the hospital for further evaluation and escalation of care, and increased pain. Findings include: Review of the complaints reported to the State Agency (SA) alleged R903 was found on the floor in the resident's room on 4/23/24 at 5:45 PM and the resident's representative was not informed of the fall, change in condition, and the need for additional pain medication related to right hip pain until 4/25/24 at 10:30 PM as the facility was preparing for to transfer the resident to the emergency department. Review of the clinical record revealed R903 was admitted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI000142466. Based on record review and interviews, the facility failed to identify and monitor a change in condition for one resident (R610) resulting in a delay in a transfer to the hospital for unresponsiveness. Findings include: On 3/11/24 a record review revealed that R610 had been admitted to the facility on [DATE] with the diagnosis of muscle weakness, pneumonia and a dislocation of internal left hip. R610 was admitted to the facility to receive therapy because the resident had fallen and had a broken hip. According to progress notes dated for 11/10/23 at 1:54 AM Nurse went in to give guest scheduled pain pill and guest was unresponsive even to sternal rub. Guest VS (vital signs) were taken BP (blood pressure) was 124/74. Guest was having constricting movements in the bed such as curling toes and fingers but would not respond to verbal cues. Nurse was unable to obtain pulse ox reading on 25L (liters) o2 (oxygen) after 20 minutes guest breathing appeared shallow. EMS…

    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 before2024-01-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report bilateral (B/L) facial bruising and right lower extremity (RLE) pain to the State Agency (SA) for one (R701) of one resident reviewed for injuries of unknown origin. Findings include: A complaint was filed with the SA on 1/22/24 that alleged in part, .On the morning of 1/11/24 . it was noted substantial amount of bruising on left side of face, large knot on top of (R701's) head, bruising on right side starting as well . Resident also complained of severe right leg pain along with new onset chest pain . nothing was reported regarding incident that happened sometime between the evening of the 10th and the 11th . Review of the closed record revealed R701 was admitted into the facility on 3/16/18 and readmitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease, atrial fibrillation and heart failure. According to the Minimum Data Set (MDS) assessment dated [DATE], R701 had moderately impaired cognition, and was dependent on…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00141671 Based on observation, interview and record review the facility failed to ensure continuous nursing professional standards were practiced for signing documents and for one (R704) of two resident reviewed for dignity/respect. Finding include: Complaints were filed with the State Agency (SA) that alleged the Director of Nursing (DON) was forging nursing signatures on the controlled substance forms and that nursing staff were not treating residents in a dignified manner. On 1/29/24 at approximately 1:20 PM, an observation of the narcotic sign-off sheet located on the medication cart (100/200 hall) was conducted. Nurse M was in charge of the cart. Nurse M reported that they had worked at the facility for approximately a year and a half. They indicated that they generally worked the day shift. During the interview, Nurse M was asked if anyone, including the DON, had ever forged their signature. Nurse M reported yes and explained that the DON signed their name on 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-11-16 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate medication storage in four of four medication carts and for one resident (R172), of four residents reviewed for medication administration and storage. Findings include: On 11/14/23 at 10:42 AM, Nurse 'A' was observed preparing medications for administration. During the observation, it was observed 2 unlabeled medication cups containing multiple pills were stored in the top right drawer of the cart. On 11/15/23 at 8:38 AM, an observation of one of the four medication carts was conducted with Nurse 'B'. During the observation it was discovered topical patches were stored in the same drawer and compartment with bleach and non-bleach sanitizing wipes. It was also discovered a pill cup with a open package of a coumadin tab (blood thinner) that had been pulled from the back-up medication supply was stored in the cart. Continued review of the cart revealed an open package of artificial tears with no resident name, and three…

    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 · Fcited before2023-11-16 · 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. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 11/14/23 between 9:25 AM-10:00 AM, during an initial tour of the kitchen, the following items were observed with Dietary Manager P (DM P): 1. An undated wrapped roast beef in the refrigerator. 2. Dried Food debris on bottom of multiple refrigerators. 3. Dried splattering on the prep cooler. 4. An opened and undated tub of thousand island dressing. 5. An opened container of cheese sauce with no open date. 5. An opened and undated bag of veggie burgers. 6. An unsealed and undated bag of french fries in a freezer. 7. Food debris on bottom of a freezer. 8. Food debris on top of the stove and dried splattering on side of the stove. 8. A dried black substance on under lid of the ice machine. On 11/14/23 at approximately 9:50 a.m., DM P was queried regarding the observations of food debris and indicated they have had trouble staffing the kitchen to…

    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 before2023-11-16 · 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 ensure a resident's right to have non-male (direct) caregivers while at the facility for one (R171) out of two residents reviewed for dignity/respect. Findings include: On 11/14/23 at approximately 10:17 AM, R171 was observed lying in bed. The resident was alert and able to answer questions asked. When asked about care provided at the facility, R171 stated they were not happy at the facility. R171 stated that on Sunday (11/12/23) evening a male CNA (certified nursing assistant) who was an Agency person not employed (employed via contract) by the facility entered her room and closed the door. The male CNA was going to change the resident's brief and he made her feel uncomfortable. The resident stated they told the supervising Nurse, who they also indicated worked for an Agency, and the Nurse accused her of not wanting a black male aide. R171 stated she told the Nurse, that she didn't care if the male aide was black, white or red, she just…

    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 · D2023-11-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and mental abuse by Certified Nursing Assistant K (CNA K) for one resident (R231) of one residents reviewed for abuse/neglect/mistreatment. Findings include: On 11/16/23 the medical record for R231 was reviewed and revealed the following: R231 was initially admitted to the facility on [DATE] and discharged on 10/28/22. A review of R231's MDS (minimum data set) with an ARD (assessment reference date) of 10/9/23 revealed R231 needed moderate assistance from facility staff with some of their activities of daily living. R231's BIMS score (brief interview for mental status) of 15, indicating intact cognition. On 11/16/23 a review of facility provided investigations involving CNA K revealed the following statements/documents pertaining to an incident that occurred on 10/8/23 involving R231. An email correspondence between the staffing agency representative and the Director of Nursing (DON) dated 10/10/23…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2023-11-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement policies and procedures for ensuring an allegation of mistreatment/verbal abuse was reported to the State Agency in accordance with section1150B of the Act for one resident (R231) of one residents reviewed for abuse/neglect/mistreatment. Findings include: On 11/16/23 the medical record for R231 was reviewed and revealed the following: R231 was initially admitted to the facility on [DATE] and discharged on 10/28/22. A review of R231's MDS (minimum data set) with an ARD (assessment reference date) of 10/9/23 revealed R231 needed moderate assistance from facility staff with some of their activities of daily living. R231's BIMS score (brief interview for mental status) of 15 indicating intact cognition. On 11/16/23 a review of facility provided investigations involving CNA K revealed the following statements/documents pertaining to an incident that occurred on 10/8/23 involving R231. An email correspondence between the staffing agency…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent resident access to an alleged perpetrator after an allegation of mistreatment was made and the investigation was still in process for one resident (R231) of one residents reviewed for abuse/neglect/mistreatment resulting in the increased potential for retaliation. Findings include: On 11/16/23 the medical record for R231 was reviewed and revealed the following: R231 was initially admitted to the facility on [DATE] and discharged on 10/28/22. A review of R231's MDS (minimum data set) with an ARD (assessment reference date) of 10/9/23 revealed R231 needed moderate assistance from facility staff with some of their activities of daily living. R231's BIMS score (brief interview for mental status) of 15 indicating intact cognition. On 11/16/23 a review of facility provided investigations involving CNA K revealed the following statements/documents pertaining to an incident that occurred on 10/8/23 involving R231. An email correspondence between 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00140216. Based on observation, interview and record review the facility failed to ensure staff followed proper Transmission Based Precautions (TBP) for one (R39) who was on Enhanced Barrier Precautions out of five residents reviewed for infection control. Findings include: On 11/14/23 at approximately 9:18 AM, during initial tour, there were several rooms, including R39's, that had an Enhanced Barrier Precaution sign on their entry door. The sign read, in part: Enhanced Barrier Precautions .Providers and staff must wear gloves and gowns for the following .Dressing, bathing/showering, transferring, changing linens, providing hygiene care, brief changes or toileting . Upon entry to R39's room, CNA (certified nursing assistant) G was observed not wearing gloves or a gown and was taking the resident to the bathroom. CNA F entered the room to assist CNA G and they did not enter the room with gloves or a gown. CNA G was asked as to the protocol/policy pertaining to Enhanced Barrier…

    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 before2023-10-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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 This citation pertains to intake: MI00139758. Based on interviews and record reviews the facility failed to timely implement treatment and interventions for an identified Moisture Associated Skin Damage (MASD) for one (R703) of three residents reviewed for pressure ulcers, resulting in the coccyx area to worsen to an identified wound with slough (Slough- is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) within four days of admission to the facility. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to provide appropriate and adequate care to prevent and treat pressure wounds. Review of the medical record revealed R703 admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis (MS), muscle weakness, unspecified protein-calorie malnutrition, paraplegia, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · 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 This citation pertains to intake(s): MI00139758 & MI00138346. Based on interviews and record reviews the facility failed to complete a comprehensive nutrition admission assessment timely (R703) and provide a meal tray (R704) to two of four residents reviewed for nutrition. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility staff to not have provided the necessary assistance to R703 with meals. Review of the medical record revealed R703 admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis (MS), muscle weakness, unspecified protein-calorie malnutrition, paraplegia, and gastro-esophageal reflux disease. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14 (which indicated intact cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of an admission Dietary Profile dated 7/17/23 (three days after the resident was admitted to 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

“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 SYMPHONY CARE NETWORK — 7 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 2 of 51.7+0.3 vs chain
Health inspection 2 of 51.7+0.3 vs chain
Staffing 3 of 52.4+0.6 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 6 homes this chain runs (chain average 1.7★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
SYMPHONY OF MICHIGAN HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2019
BENOIT HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST20%since 09/01/2019
CALUMET SOUTH LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 09/01/2019
FAIRHOME TRUST UAD 12312012Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST20%since 09/01/2019
GZLT HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST10%since 09/01/2019
WILLOW DELTA TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST15%since 09/01/2019
KRUPP, ARIIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL10%since 09/01/2019
SENDEROWICZ, YOSSIIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 09/01/2019
TRUISTOrganization5% OR GREATER SECURITY INTERESTsince 09/01/2019
RAZA, ALIIndividualW-2 MANAGING EMPLOYEEsince 07/12/2021
HARTMAN, DAVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
DRAKE LOUIS ENTERPRISE, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019

CMS files one row per role, so the 15 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$13.3M
Net patient revenuemost recent cost report
+5.3%
Operating marginrevenue minus expenses
$729K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 7%Medicare 18%Other / private 75%

This home reported $729K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$307per resident / day
operating cost
$9,332per month
≈ monthly operating cost
$324per 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 235615. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, 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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