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

Tuscola County Medical Care Facility

1285 Cleaver Road, Caro, MI 48723 · Government - County · 159 certified beds · (989) 673-4117 Medicare & Medicaid certified

Call the home — (989) 673-4117 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

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

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 (5/5)
  • lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score

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

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

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

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
620 N State St · (989) 672-0144 · Call to confirm hours
Pharmacy
1121 E Caro Rd · (989) 673-7922 · Call to confirm hours
Grocery
ALDI0.4 mi
1181 E Caro Rd · (855) 955-2534 · Call to confirm hours
Park
1480 Cameron Rd · (855) 788-6500 · 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 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 improved from 4 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.5%10.8%15.4%better
Long-stay residents who lose too much weight4.1%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.8%0.9%better
Long-stay residents with a urinary tract infection0.2%1.5%2.0%better
Long-stay residents with depressive symptoms6.5%4.3%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.2%3.0%3.3%better
Long-stay residents whose ability to walk worsened9.7%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.9%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers1.9%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control23.3%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table15.2%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine98.9%79.5%79.4%better
Short-stay residents rehospitalized after admission20.8%24.0%22.6%typical
Short-stay residents with an outpatient ER visit11.9%11.7%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.311.841.67better
Long-stay outpatient ER visits per 1,000 resident days1.261.641.80better

§ 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.

53.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 117 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.9%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
55.6%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 55.6% 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 54 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 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF53.9%CMS range 45.2–61.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.0–13.010.7%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 discharge55.6%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 discharge48.1%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 discharge63.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%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 hospitalization5.7%CMS range 3.0–11.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 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

1.00
RN hours/ resident / day
1.08
LPN hours/ resident / day
3.87
Aide hours/ resident / day
5.95
Total nurse hours/ resident / day
0.54
RN hoursweekends
24.5%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 159 beds and averages 135.3 residents a day — about 85% occupied, or roughly 24 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 5.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.87 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.12 hrs/resident/day on weekends vs 6.28 on weekdays — 18% thinner on weekends. RN hours go from 1.19 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 24% 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

7
deficiencies at the latest standard inspection (2025-12-12)
9
at the previous standard inspection (2024-10-17)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2023-10-27 · 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 development and worsening of pressure ulcers for two residents (Resident #24, Resident #37), resulting in the worsening of a skin injury for Resident #24 and a facility-acquired Stage III pressure ulcer for Resident #37. Findings include: Record review of facility 'Skin Care' policy dated 11/8/2022 revealed a head-to-toe skin assessment is completed and documented on all residents upon admission by a licensed nurse and/or registered nurse, and weekly skin assessment thereafter by licensed or registered nurse that is documented in EMR. Skin Risk assessment to be completed on admission, weekly for 4 weeks then quarterly with MDS schedule and as needed. All residents will be reviewed for appropriate pressure relief interventions in place. Nursing will assess and plan additional interventions as needed. The focus of the skin assessment is to: (1.) Promote the health of the skin and identify residents at risk for skin breakdown. (2.)…

    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 · F2025-12-12 · 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 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 who consume food from the kitchen. Findings Include:On 12/9/25 at 10:15 AM, an initial tour of the kitchen was conducted with Dietary Manager (DM) C. The following observations were made: -A drain from the walk-in freezer drained into a hole in the floor. The tube was lower than the floor. -A drain that the DM reported she thought it was for the ice machine, was observed going into a cut out from the floor drain area and did not have an air gap. The drainpipe was below the level of the floor. There was another plastic tubing in the cut-out floor drainage area that was wrapped around the inside of the drain box in the floor. The tubing was below the level of the floor and debris was noted where the piping lay. -Osmosis system had a black tube inside slotted box drain in the floor. The black tube was below the level of the floor. -Nosey cups were stored in a plastic container with the lid…

    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 · F2025-12-12 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 and interview, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination of the water supply, affecting all residents. Findings include: On 12/11/2025 at approximately 12:41pm-1:24pm during the environmental tour with the Life Safety Officer B, observed a hose attached to a spigot without a backflow preventer at the cold water line located in the boiler room. On 12/11/2025 at approximately 12:41pm-1:24pm observed the water softener drain line sitting directly inside a drain. On 12/11/2025 at approximately 12:41pm-1:24pm observed a utility sink with a chemical feed downstream of an atmospheric vacuum breaker located in the housekeeping closets in Rooms 278, 206, 136, and 178. On 12/12/2025 at 9:00-9:40am observed a utility sink with an attached chemical dispenser downstream of an atmospheric vacuum breaker located in the janitor's closet in Cortland House. On 12/12/2025 at 9:00-9:40am observed a utility sink…

    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 · Ecited before2025-12-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents' rights were being met by 1) Ensuring that call lights were within reach or easily accessible to residents and/or 2) Ensuring that call lights were responded to in a timely manner for four residents (R11, R74, R78 and R121) of four residents sampled for accommodation of needs and also a Confidential Group of Residents. Findings include:Resident #11 (R11): On 12/11/25 at 12:32 PM, an observation was made of Resident 11 sitting up in his wheelchair, propelling himself in his room. An observation was made of the Resident's call light positioned on the floor underneath the bed. The call light hung from the wall and the bed was positioned up against the wall. The call light was lying on the floor between the wall and the bed. The call light was not within reach for R11. The Resident was asked for help. A staff member was alerted to the Resident needing assistance from staff found in the hallway and was informed of the call…

    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 · E2025-12-12 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that food was palatable and maintained at a palatable temperature for one resident (Resident #68) of three residents reviewed for food palatability and a group of confidential residents. Findings include: Cold food complaints with a Confidential Group of Residents On 12/10/25 at 10:32 AM, a Confidential Group of Residents were interviewed. The group consisted of 18 Residents. The majority of Residents were able to answer questions and engaged in a group conversation. The Residents were asked about issues they had with the care received at the facility. The Confidential Group of Residents reported concerns with food being too cold to eat. Six of the Residents reported that food was not warm enough sometimes when they received the food in their room and other residents reported that sometimes the food that should be warmer was cold in the dining room as well. One resident reported getting eggs that were not at a good temperature 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 · D2025-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure ongoing collaboration with hospice care for one resident (R56) of two residents sampled for hospice care, resulting in the absence of documentation of care provided by hospice. Findings include:Resident #56 (R56): R56 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia, prediabetes and hypothyroidism. On 12/11/2025 at 3:00PM, record review of the Electronic Medical Record (EMR) revealed a physician's order for hospice care is present in the chart and dated 5/2/25. On 12/11/2025 at 3:05PM, record review of the EMR did not reveal any hospice documentation for R56. On 12/11/2025 at 3:13PM, Unit Manager (UM) A, provided the hospice binder for R56 that is stored at the nurse's station. On 12/11/2025 at 3:14PM, record review of the hospice binder was conducted. Record review revealed documents of Nurse and Certified Nursing Assistants (CNA) visits from 5/8/25 to 8/1/25. The documents…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-12 · 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 implement and operationalize policies and procedures for pressure ulcer management for one resident (Resident #33) of five residents reviewed resulting in lack of comprehensive identification and assessment of wound etiology and lack of correct application of pressure reduction devices. Findings include:Resident #33:On 12/11/25 at 10:07 AM, Resident #33 was observed in their room lying in bed. The Resident was positioned flat on their back with bilateral Prevalon heel boots (soft, cushioned boot which floats the heels off of a mattress or surface for pressure reduction) in place. The boots were positioned incorrectly and Resident #33's heels were not in the open area designed for the heel in the boot. Resident #33's heels were positioned directly on the side of the boot. An interview was completed at this time. When queried if they were having any pain, Resident #33 replied in my feet. When asked to rate their pain on a scale of zero 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-17 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility 1) Failed to ensure analyzed observational data of personal cares with a continued spread of a Multi-Drug Resistant Organism (MDRO), 2) Failed to ensure proper Personal Protection Equipment (PPE) use, 3) Failed to ensure proper hand hygiene, 4) Failed to ensure proper wound care, 5) Failed to ensure proper perineal (peri) care for two residents (Resident #40, Resident $45) of two residents reviewed for peri-care and 6) Failed to prevent a wound infection for one resident (Resident #45) of three residents reviewed for wound care, resulting in the continued in-house spread of Proteus Mirabilis infections, staff not following enhanced barrier precautions and providing clean cares with the likelihood of the further spread of infections. Findings include: On 10/16/24, at 11:56 AM, a record review of the facility provided infection control line listing revealed the following case counts of In-House MDRO Urinary Tract Infections (UTI): 5/2024 Case List…

    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 · E2024-10-17 · tag F0656 — failed to write and follow a full care plan — pattern
    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 interview and record review, the facility failed to develop person-centered comprehensive care plans for Code Status preferences for five residents (Resident #4, Resident #17, Resident #22, Resident #66, Resident #68) of 29 residents reviewed for care plans, resulting in the potential for residents not to receive individualized care, which could lead to a decline in condition, and/or a negative outcome. Findings Include: A record review of the facility policy titled, Comprehensive Care Plan, Care plan review and Care Plan Conferences, date implemented [DATE], date reviewed [DATE] and date revised [DATE], provided (The facility) will ensure that all residents have a Baseline Care Plan completed per the Baseline Care Plan Policy, and a comprehensive Care Plan in the e- chart within 7 days of completion of section Z of the admission MDS assessment . The Care Plan will provide staff with guidelines on resident care needs . Resident #4: Advance Directives A record review of the Face sheet and Minimum Data…

    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 · Ecited before2024-10-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to follow facility policy for indwelling catheter use for five residents (R17, R22, R51, R52, R106) of six residents reviewed, resulting in physician's orders not having catheter size, dignity bags touching the floor and recurrent UTI's (urinary tract infections). Findings include: Resident #52 (R52): R52 is [AGE] years old and was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia, neuromuscular dysfunction of the bladder and history of urinary tract infections. On 10/14/24 at 10:27AM, observation revealed that R52 had an indwelling catheter, the urine collection bag was hanging below the bed, covered by a dignity bed and off the floor. On 10/16/24, record review of the admission MDS (Minimum Data Set) revealed that R52 was admitted with an indwelling catheter. On 10/16/24, record review of R52's care plan revealed a care plan for the indwelling catheter that was last revised on 12/27/2023. The…

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

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

    Based on observation, interview and record review, the facility failed to ensure that medications and medical supplies were stored and disposed of per professional standards of practice in two of five medication rooms resulting in expired medications and medical supplies, lack of refrigerated vaccine temperature monitoring per CDC recommendations, and the potential for residents to have procedures and testing completed with expired supplies and to receive expired medications with altered potency and efficacy. Findings include: A tour of the Second Redwood Medication Room was completed with Unit Manager Registered Nurse (RN) T on 10/17/24 at 8:34 AM. The following exited medications and medical supplies were present in the medication room: - ProSource NoCarb 15-gram Protein, 30 fluid ounce (oz) container, Expired: 9/28/24 - UTI-Stat, 30 fluid oz container, Expired 7/27/24 - 100 tablet bottle of Aspirin 81 mg tablets, Expired: 9/24 - Three bottles of Prevacid 15 mg tablets with 14 tablets per bottle for Resident #14, Expired 6/24 - Universal Viral Transport for Viruses (Covid)…

    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 12 citations
  • Potential for harm · Dcited before2024-10-17 · 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 care that was dignified and respectful treatment for two residents (Resident #96 and Resident #114) of two residents reviewed, resulting in a lack of acknowledgement and/or response to Resident #96's verbalization of discomfort and Resident #114's request for assistance, and the likelihood for feelings for insignificance and psychosocial distress utilizing the reasonable person concept. Findings include: Resident #96: On 10/15/24 at 8:33 AM, Resident #96 was observed in the dining room of the locked dementia care unit of the facility. The Resident was sitting in their wheelchair at a table with a plastic cushion behind their back and was repeatedly saying, Oh my back, oh my back. There were other residents sitting at the table eating as well as a Certified Nursing Assistant (CNA) U. Two other staff members were present in the dining room within hearing distance of Resident #96. When asked if they were okay, Resident #96 responded,…

    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 · D2024-10-17 · 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 Based on observation, interview and record review, the facility failed to ensure a safe environment to prevent skin tears and bruising for one resident (Resident #22) of 8 residents reviewed for accidents, resulting in Resident #22 suffering repeated skin tears and bruising. Findings Include: Resident #22: Accidents A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #22 identified a readmission to the facility on 8/18/2023 with diagnoses: Diabetes, heart disease, heart failure, COPD, arthritis, Alzheimer's, and a history of falls. The MDS assessment dated [DATE] indicated the resident had a BIMS score of 9/15 with moderate cognitive decline and needed assistance with all care. On 10/14/2024 at 11:53 AM, Resident #22 was observed lying in bed; there were two handrails on the sides of the bed (grab bars). He was observed to have thick tan colored arm sleeves from his wrist to mid-upper arm on. Certified Nurse Aide/CENA P said the resident wore the sleeves to protect his arms because…

    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 before2024-10-17 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update and follow care planned interventions for one resident (Resident #51) of two residents reviewed for tube feeding, resulting in the head of the bed being at 19 degrees during tube feeding with the likelihood of decreased tube feeding dose, aspiration and/or pneumonia. Findings include: Resident #51: On 10/16/24, at 11:00 AM, a record review of Resident #51's electronic medical record revealed a readmission on [DATE] with diagnoses that included Dysphagia, Multiple Sclerosis and Pneumonitis due to Inhalation of food and vomit. Resident #51 required extensive assistance with Activities of Daily Living and had intact cognition. A review of the physician orders revealed . Jevity 1.5 Cal Liquid (Nutritional Supplements) Directions Give 60 ml enterally . Start Date 10/9/2024 . Ensure HOB is elevated 30 degrees for duration of feeding and 60 minutes after feeding complete Line up yellow markings on bed and headboard . Start Date 09/30/2024…

    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 before2024-10-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow physician's orders for oxygen administration for one resident (Resident #117) of one resident reviewed for oxygen administration, resulting in the oxygen flow rate being administered not matching the [NAME] or care plan. Findings include: Resident #117 (R117): R117 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include COPD (Chronic Obstructive Pulmonary Disease), chronic pulmonary edema, anxiety and anemia. On 10/14/24 at 09:56AM, R117 was observed sitting in a reclining chair with oxygen being administered at 3LPM (liters per minute) via NC (nasal cannula). The oxygen tubing was dated 10/10. On 10/15/24 at 08:58AM, R117 was observed sleeping in bed, oxygen was being administered at 3LPM via NC. On 10/16/24 at 03:57PM, R117 was asked if they are on oxygen continuously. R117 stated they use oxygen all the time and currently use 3LPM. The oxygen concentrator was observed set to 3LPM and the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-17 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement a yearly Quality Assessment Process Improvement (QAPI) Plan specific to the facility's population and concerns to ensure correction of deficiencies necessary to ensure resident safety and quality of life for 127 residents of the facility, resulting in the potential for negative physical and psychosocial outcomes for all 127 residents of the facility. Findings Include: FACILITY QAPI and QAA On 10/17/24 at 2:23 PM, the Administrator was interviewed about the facilities QAA/QAPI program. The Administrator said he oversaw the QAPI program at the facility; he said the committee met monthly, except for December. He said they met the quarterly meeting requirements. When asked to review the committee attendance forms. The Administrator provided a document with 3 paragraphs; he said he had typed the names of those in attendance and those that were not present for the meetings and were excused. The entries he provided did not meet the attendee requirements as the Medical Director/Physician did not attend on one of 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-27 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow professional standards of practice by ensuring four residents' (#11, #35, #79 and #83) comprehensive quarterly assessment progress notes were inputted timely, resulting in the four residents having 2-3 missed assessment progress notes due to lack of oversight and time management. Findings include: Resident #79: During initial tour on 10/25/2023, Resident #79 was observed resting in her room. Further review of Resident #79's medical records revealed she was admitted to the facility on [DATE] with diagnoses that included, Vascular Dementia, Hemiplegia and Hemiparesis, Schizophrenia, Bipolar Disorder, Epilepsy, and Insomnia. Further review was completed of Resident #79's record and yielded the following results: Social Work Quarterly Assessment Progress Notes: After April 2023 there was no quarterly assessments completed in the months of July 2023 and October 2023. Resident #35: On 10/26/2023, a review was completed of Resident #35'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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the provision and care of indwelling urinary catheter drainage bags per professional standards of practice for five residents (Resident #24, Resident #37, Resident #46, Resident #61, and Resident #235) of six residents reviewed, resulting in urinary catheter drainage bags and tubing being maintained in an unsanitary conditions and a lack of comprehensive assessment and monitoring of urinary catheters for residents. Findings include: Resident #46: On 10/25/23 at 2:13 PM, an observation of Resident #46 occurred in their room. One side of the Resident's bed was positioned against the wall. Resident #46 was in bed, positioned on their back, with their eyes closed. An indwelling urinary catheter drainage bag was positioned directly on the floor. Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses which included urinary retention, Benign Prostatic Hyperplasia (BPH), skin cancer, and heart disease.…

    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 · E2023-10-27 · tag F0694 — pattern
    Provide for the safe, appropriate administration of IV fluids 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 implement policies and procedures to ensure the provision of Peripherally Inserted Center Catheter (PICC- intravenous [IV] catheter inserted in the body through the arm that extends to the heart utilized for long term administration of medications) care per professional standards of practice for one resident (Resident #50) of one resident reviewed, resulting in a lack of appropriate port cleaning prior to access, inappropriate flushing technique including Resident #50's PICC line being flushed unnecessarily with heparin 41 times during October 2023, and the potential for PICC complications and infection. Findings include: Resident #50: On 10/25/23 at 12:58 PM, signage outside of Resident #50's room indicated the Resident had Enhanced Barrier Precautions in place. The signage specified, Providers and Staff Must . Wear gloves and gowns for the following Device Care or Use: Central line . Wound Care . Upon entering the room, Resident #50 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure clean respiratory equipment storage for four residents (Resident #41, Resident #57, Resident #122, Resident #135), resulting in exposed Continues Positive airway Pressure (CPAP) mask and oxygen equipment with the likelihood of cross contamination of the equipment causing respiratory infections. Findings include: Resident #122: On 10/26/23, at 8:30 AM, Resident #122 was resting in bed. Their CPAP mask was resting face up on their nightstand. Resident #122 was asked if they wore their CPAP in the night and Resident #122 stated, no that nobody came in last night to help him. On 10/26/23, at 2:44 PM, an observation along with Nurse N of Resident #122's CPAP mask that remained exposed on the nightstand was conducted. Nurse N stated, we normally clean it and hang it form the pole but I have been too busy. Nurse N was asked how they normally clean it and Nurse N stated, they use dawn soap. Nurse N was asked how the mask was normally stored…

    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 · Ecited before2023-10-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure that 4 of 5 medication carts were free from loose tablets and capsules, and ensure proper labeling of medications, resulting in opened and undated medications, the likelihood of cross contamination and ineffective medications. Findings include: Record review of the facility 'Storage of Medication' policy dated 10/3/2022 revealed medications are stored in containers that meet legal requirements. Medications and biological's are stored properly, following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Record of facility provided pharmacy Long Term Care 'Medication Expiration Date Requirements' dated 2/2/2023 revealed multiple medications and solutions with varying expiration dates/days after opening. Medication Storage and Labeling: Observation was conducted on 10/25/23 at 11:45…

    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 before2023-10-27 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement procedures for tube feeding equipment storage, per professional standards of practice for one resident (Resident #57) of one resident reviewed, resulting in a lack of cleaning and sanitary storage of tube feeding equipment and the likelihood for contamination and illness. Findings include: Resident #57: On 10/25/23 at 12:08 PM, signage was noted outside of Resident #57's room indicating the Resident had contact, droplet, and airborne transmission-based isolation precautions in place. On 10/25/23 at 4:52 PM, an interview was completed with Certified Nursing Assistant (CNA) X. When queried regarding the reason for the transmission-based isolation precautions, CNA X revealed Resident #57 had Covid-19. An observation of Resident #57 occurred on 10/25/23 at 5:00 PM. Resident #57 was observed in their room in bed. The Resident's eyes were closed. A tube feeding bag was observed on an IV pole in the room and a tube feeding syringe 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-12-12 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 daily posted nurse staffing data included delineation of licensed nursing staff and accurate documentation of actual hours worked, resulting in incomplete and inaccurate nurse staffing information. Findings include:On 12/10/25 at 2:49 PM, the facility posted nurse staffing hours were observed posted in the main hallway of the facility. The posted hours included a section for Licensed Nursing Staff but did not distinguish between the number and/or hours of Registered Nurses (RN) versus Licensed Practical Nurses (LPNs) who were working. An observation of the posted nurse staff information on 12/11/25 at 10:00 AM revealed the same form was used to post facility nurse staffing data and the number/hours of RNs and LPNs were not separate on the form. An interview was completed with the facility Administrator on 12/11/25 at 12:03 PM. When queried how an individual reviewing the posted nurse staff information knew if there was an RN in the building, the Administrator reviewed the facility posted staffing form 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
TUSCOLA COUNTYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/01/1957
BOULTON, ALISSAIndividualMANAGING CONTROL - GOVERNING BODYsince 12/01/2025
DEWALD, CHERYLIndividualMANAGING CONTROL - GOVERNING BODYsince 07/14/2025
MORRIS, SUE ANNIndividualMANAGING CONTROL - GOVERNING BODYsince 09/01/2017
AQIL, ARSHADIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/20/2006
HUIZAR, CANDIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/10/2015
MCDANIEL, JIMMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/18/2019
PALMER, MANDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/30/2022
RABIDEAU, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
ROOT, MARGARETIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/23/1996

CMS files one row per role, so the 16 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$23.2M
Net patient revenuemost recent cost report
+3.2%
Operating marginrevenue minus expenses
$8K
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 80%Medicare 4%Other / private 15%

About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $8K 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

$478per resident / day
operating cost
$14,522per month
≈ monthly operating cost
$494per 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 235089. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-12, 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.

What to do next