Eaton County Medical Care Facility
530 W Beech Street, Charlotte, MI 48813 · Government - County · 142 certified beds · (517) 543-2940 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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 a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (18) — 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.
| 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
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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 | 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 held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.9% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.1% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.1% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.7% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.2% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.4% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.3% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.0% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.1% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.2% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.4% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.7% | 11.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.97 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.77 | 1.64 | 1.80 | typical |
§ 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.
65.2% 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 169 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 83 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 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 65.2%CMS range 57.6–72.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 7.6–13.5 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 66.3% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 61.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 65.1% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 4.9%CMS range 2.7–8.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.74 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 142 beds and averages 124.7 residents a day — about 88% occupied, or roughly 17 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 6.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.21 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 5.33 hrs/resident/day on weekends vs 6.71 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.07 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.
- Actual harm · G2023-11-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 facility failed to: 1) accurately assess, monitor and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R37) of three reviewed for pressure ulcers, resulting in facility acquired stage 3, a deep tissue pressure injury, and unstageable pressure wounds and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Review of the facility, Skin Care Policy, dated 2/22, reflected, It is the policy of the [named facility] to routinely protect residents/patients from skin breakdown and injury. All nursing staff when working with residents/patients in giving care will inspect, apply preventative treatments (when necessary), and document each resident/patient ' s skin for any changes and to communicate skin concerns to the wound…
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.
- Potential for harm · Fcited before2026-02-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 118 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 02/10/2026 at 10:20 A.M., An initial tour of the food service was conducted with Culinary Services Manager E. The following items were noted:Walk-In Freezer: The air curtain strips were observed (cracked, brittle, missing). The entrance door gasket was also observed (worn, torn, etched). Frozen water condensation droplets and severe heavy frost deposits were further observed on the walk-in freezer ceiling, adjacent to the refrigeration fan unit. The effected area measured approximately 8-feet-wide by 8-feet-long. Culinary Services Manager E indicated she would contact maintenance for necessary repairs as soon as possible.The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets…
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.
- Potential for harm · E2026-02-13 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide impactful and meaningful activities for four Residents (#24, #55, #104, & #109) of four residents reviewed for activities.Findings include:Resident #55 (R55) Review of the clinical record and Minimum Data Set (MDS) assessment dated [DATE] revealed R55 was admitted to the facility on [DATE] with diagnoses that included dementia. According to the MDS, R55 had long and short-term memory impairment and was severely impaired regarding daily decision-making skills. R55 resided on the facility's secured dementia unit. On [DATE] at 11:32 AM, during the screening process R55 was observed sitting in his wheelchair sleeping in the secured units lounge/common area. Several other residents were observed sitting in the same area, 4 of which were also asleep. On [DATE] at 2:26 PM, R55 was observed in common area on unit, with approximately 6 other residents, the television was broadcasting a music channel but it was barely audible. R55 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.
- Potential for harm · Dcited before2026-02-13 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #8) of 24 reviewed for MDS assessments. Review of the clinical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 8 (R8) was admitted to the facility on [DATE] with acute respiratory failure. The MDS dated [DATE] revealed Section N0415 question 1. E. was coded Yes for having been administered an anticoagulant medication within the last 7 days. Review of R8's Medication Administration Record (MAR) for November 2025 and monthly Physician orders for November 2025 revealed, R8 was not prescribed or administered an anticoagulant medication. On 02/12/26 at 3:10pm, during an interview with Registered Nurse/MDS Coordinator C, R8's November MDS, MAR and physician orders were reviewed. Registered Nurse/MDS Coordinator C agreed there was no documentation to support R8 was administered an anticoagulant medication. RN C acknowledged the MDS dated [DATE]…
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.
- Potential for harm · Fcited before2024-12-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During a tour of the kitchen, starting at 12:54 PM on 12/17/24, it was observed that a box of vegetables and large bag of potatoes were found stored on the floor of walk-in cooler three. An interview with Head Chef (HC) F found that deliveries come Monday and Thursday. During a tour of the walk-in freezer, at 1:42 PM on 12/17/24, it was observed that multiple boxes of food product were found stored on the floor such as vegetables and buttermilk biscuits. An interview with HC F found that the staff member who regularly puts product away has been off work. According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is 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.
- Potential for harm · Fcited before2024-12-20 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility, at 10:35 AM on 12/18/24, an interview with Maintenance (M) I found that Building Services Director (BSD) H handles the Water Management Plan (WMP). During a tour of Unit A soiled utility room, at 10:40 AM on 12/18/24, it was observed that water in the hopper was found to be low in the bowl. After flushing the hopper, the water in the bowl filled up with roughly two times the amount of water, indicating that the fixture is not regularly flushed to remove stagnation due to lack of use. During a tour of the Garden Grove janitors'…
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.
- Potential for harm · E2024-12-20 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 their medication error rate was below 5% when five medication errors were observed from a total of 35 opportunities for four residents (R42, R58, R100, and R129) of seven reviewed resulting in a medication error rate of 14.29%. Findings include: Resident 100 (R100) Review of the medical record revealed R100 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/24 revealed R100 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/19/24 at 7:53 AM, Licensed Practical Nurse (LPN) D was observed preparing and administering medications to R100. LPN D measured 17 grams of Miralax (laxative medication) powder and placed the powder in a plastic cup. R100 was seated at a dining room table eating breakfast and had some coffee in a cup. LPN D handed R100 the cup of Miralax powder. R100 then poured the powder 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.
- Potential for harm · Ecited before2024-12-20 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 and interview, the facility failed to dispose of expired medications in two of four medication carts, appropriately store refrigerated medications in one of three medication storage rooms reviewed, and secure medications (R97), resulting in the potential for decreased efficacy of medications, medication contamination, medication errors and adverse side effects in a current facility census of 127 residents. Findings include: Review of the facility provided medication cart and room map reflected 6 medication rooms and 7 medication carts. During an observation on 12/19/24 at 1:48 PM, Registered Nurse(RN) W unlocked the, rehab high medication cart. Located in the cart was an open bottle of Benadryl 25mg with manufacture expiration dated of 10/2024 and Insta Glucose with manufacture expiration date of 6/2023. During an observation and interview on 12/19/24 at 2:50 PM, License Practical Nurse(LPN) X unlocked the Pine Ridge Medication resident medication refrigerator, located in the medication room, with several resident medications as well as unlabeled frozen food in…
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.
- Potential for harm · D2024-12-20 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 1 residents (#329) of 2 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers potentially affecting up to the facility census of 127 residents. Findings include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician.…
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.
- Potential for harm · D2024-12-20 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act 42CFR483.12(c) Findings include: Resident #22 (R#22) Review of the medical record reflected R22 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Paraplegia, Vascular Dementia, Speech and Language deficits following other Diagnosis, Cerebrovascular Disease, Dysphagia Oropharyngeal Phase, Weakness and Pathological Fracture, left Humerus, subsequent Fracture with routine healing. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/16/2024, revealed R22 had a Brief Interview of Mental Status (BIMS) of 99 (count not answer) out of 0 to 15. Under section G0100, Activities of Daily Living (ADL) assistance reveals R22 was dependent of all care. During an interview on 12/18/24 at 08:35 AM, family member Y stated that R22 suffered a broken arm,…
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.
- Potential for harm · D2024-12-20 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 ensure all injuries of unknown source were thoroughly investigated, in one of one resident (R#22) reviewed for abuse, resulting in the potential for injuries of unknown origin not being investigated. Findings include: Resident #22 (R#22) Review of the medical record reflected R22 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Paraplegia, Vascular Dementia, Speech and Language deficits following other Diagnosis, Cerebrovascular Disease, Dysphagia Oropharyngeal Phase, Weakness and Pathological Fracture, left Humerus, subsequent Fracture with routine healing. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/16/2024, revealed R22 had a Brief Interview of Mental Status (BIMS) of 99 (could not answer) out of 0 to 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R22 is dependent of all care. During an interview on 12/18/24 at 08:35 AM, family member…
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.
Show the remaining 7 citations
- Potential for harm · Dcited before2024-12-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accurately complete a Minimum Data Set (MDS) assessment for one resident (#20) of 21 residents reviewed for accurate assessments. Findings Included: Resident #20 (R20) Review of the medical record revealed R20 was admitted to the facility 07/13/2018 with diagnoses that included heart failure, chronic kidney disease, end stage renal disease, dependence on renal dialysis, atrial fibrillation, type 2 diabetes, peripheral vascular disease (PVD), hypothyroidism (low thyroid hormone), atherosclerosis (plaque in arteries), hypotension, pneumonia, insomnia, depression, anemia (low red blood cells), and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date of 09/18/2024, revealed R20 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 12/18/2024 at 08:55 a.m. R20 was observed sitting up in a chair beside her bed. R20 explained that she had been…
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.
- Potential for harm · D2024-12-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 interview and record review, the facility failed to complete adequate monitoring for the use of an anticoagulant (blood thinner) medication for one (R100) of five reviewed. Findings include: Review of the medical record revealed R100 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/24 revealed R100 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician' Order dated 11/11/24 revealed an order for Coumadin (blood thinner medication) 8.5 milligrams (mg) at bedtime for atrial fibrillation. Review of the Physician's Order dated 10/4/24 revealed an order to check PT/INR (prothrombin time/international normalized ratio-measures how long it takes the blood to clot) every Monday. Review of the Physician's Order Note dated 12/9/24 revealed Reviewed PTINR with provider .continue with same dose of coumadin [every day…
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.
- Potential for harm · E2024-08-09 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation includes intake MI00144331. Based on observation, interview and record review, the facility failed to act promptly on grievances and or concern forms reported in and out of resident council meetings and provide responses and resolutions to 26 grievances filed in the last six months, as reported during a confidential resident council meeting, resulting in unresolved resident concerns and decreased quality of life. Findings include during a confidential interview with resident council group on 08/07/24 at 2:30 PM in one Community and 08/07/24 at 3:00 PM in the second Community where 18 residents attended. The last six months concern forms were reviewed and discussed for resolution. Concerns shared during two private meetings on 08/07/24 at 2:30 PM in one Community and 08/07/24 at 3:00 PM in the second Community. 1) Resident Council Meeting had to be split into two separate meetings due to over crowding in the room they usually met in. 2) Resident Council Confidential interview stated the meetings were recorded and some residents were uncomfortable speaking up about…
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.
- Potential for harm · Fcited before2023-11-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 1) maintain sanitary food and non-food contact surfaces, 2) store chemicals away from food, 3) maintain equipment, and 4) provide ventilation for steam exhausting equipment, resulting in the potential for foodborne illness, chemical contamination, and improper ventilation. These deficient practices affect all 112 residents who consume food from the kitchen. Findings include: On 10/30/23 at 10:17 AM, the ice scoop holder, located in the main kitchen, was observed to have discolored water accumulating at the bottom. At this time, Director of Dietary Services (DDS) C took the ice scoop holder to the dish room to be washed. On 10/30/23 at 10:22 AM, the Steam & Hold steamer was observed to have steam exhausting through the door gasket while the door was shut, indicating the door gasket is not sealing properly. A large rag was observed to be placed underneath the steamer to collect moisture accumulation from the faulty gasket. Additionally, the Steam & Hold steamer was not positioned under a ventilation hood 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.
- Potential for harm · D2023-11-01 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
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 MI00139713 and MI00139715. Based on interview and record review, the facility failed to permit a resident to return to the nursing home following a hospitalization stay, in 1 of 3 residents reviewed for hospitalization (R317), resulting in loss of home, limited access to social support and decreased quality of life. R317's Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/08/23 revealed he was admitted on [DATE]. R317 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 07 (00-07 Severe Impairment). The same MDS revealed R317 had physical behavioral symptoms directed toward others that occurred 1 to 3 days during the 7-day look-back period. R317 had verbal behavioral symptoms directed toward others that occurred 1 to 3 days during the 7-day look-back period. The same MDS indicated R317 received antipsychotic medication on a routine basis. Behavior Progress Notes dated 6/25/23 at 9:24 AM revealed R317 walked out…
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.
- Potential for harm · Dcited before2023-11-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 appropriate medication storage for one of three medication carts. Findings include: During the initial tour of the facility on 10/30/23 at 10:40 a.m, revealed the facility had 6 medication carts. During an observation and interview on 10/31/23 at 4:19 PM, Licensed Practical Nurse(LPN) J unlocked the Melody Trail medication cart. This surveyor opened the second drawer and observed eight medication cups with several unidentified medications in each cup. LPN J reported she had prepared evening medications in advance for the eight resident that lived in the following rooms: 300, 302, 304, 305, 311, 313, 317 and 323 because it was easier. During an interview on 10/31/23 at 5:14 PM, Registered Nurse (RN) K reported medications should not be prepared in advance in cups for several residents at one time because of increased risk for medication errors. RN K reported the facility Policy and Procedure indicates to prepare medications just prior to administering. During an interview on 11/01/23 at 2:55 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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 Personal Protective Equipment (PPE) was worn per standards of practice for one residents (Resident #85) of 8 residents reviewed during medication pass, resulting in the potential for the transmission/transfer of pathogenic organisms and cross contamination for vulnerable residents. Findings Include: During an observation on 10/31/23 at 8:10 a.m., Registered Nurse (RN) L entered R85 room after preparing several medication to be administered through R85's PEG tube. This surveyor observed a sign posted outside R85 room for Enhanced Barrier Precautions that included use of gown and gloves. RN L administered R85 medications via the Peg tube with use of gloves only. RN L returned to the medication cart and had to return to R85 a second time to administer additional medications with the observed use of gloves only. During an interview on 11/01/23 at 2:55 PM, Director of Nursing (DON) B reported would expect staff to use gown and gloves during medication pass for resident with PEG tube who had Enhanced…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EATON COUNTY HEALTH AND REHABILITATION SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/1966 |
| RICHARD, MARTHA | Individual | W-2 MANAGING EMPLOYEE | — | since 11/15/2004 |
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.
About 77% 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 $146K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
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.
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 235027. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-13, 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.