Medilodge of Cheboygan
824 South Huron, Cheboygan, MI 49721 · For profit - Limited Liability company · 85 certified beds · (231) 627-4347 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
- it has 2 actual-harm citations
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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
- the CMS record shows $29,348 in federal fines (most recent 2024-09-26)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 13.8% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.8% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.4% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 0.9% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.1% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.1% | 19.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 15.7% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.2% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.7% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.2% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.6% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.33 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.64 | 1.64 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.4% 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 104 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 56 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 48% 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 | 54.4%CMS range 43.5–63.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 7.2–13.8 | 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 | 67.9% | 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 | 64.3% | 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 | 60.7% | 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 | 95.3% | 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 | 0.0% | 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 | 3.5% | 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 | 9.3%CMS range 6.3–13.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 85 beds and averages 77.5 residents a day — about 91% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.28 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.92 hrs/resident/day on weekends vs 4.04 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 1.47 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 13 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · G2025-11-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to intake #2661622Based on interview and record review, the facility failed to protect the right of one Resident (R1) to be free from physical and verbal abuse by a staff member of three residents reviewed for abuse. This deficient practice resulted in psychosocial harm including feelings of humiliation and fear based on the reasonable-person concept. Findings include:A facility-reported incident (FRI) investigation summary submitted to the state agency on 11/3/25 disclosed Certified Nurse Aide (CNA) A and CNA B witnessed CNA C abuse Resident #1 (R1) while rendering post-fall assistance to R1 on 10/26/25. The facility investigation substantiated the abuse. Review of the electronic medical record (EMR) of R1 revealed an admission date of 3/18/25 with a primary diagnosis of cerebral infarction (stroke). Additional diagnoses included but were not limited to: Alzheimer's disease, age-related cognitive decline, major depressive disorder, cognitive communication deficit, weakness, fatigue, 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.
- Actual harm · Gcited before2024-09-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00147076 and MI00147197. Based on observation, interview and record review, the facility failed to ensure appropriate assessments and communication for change in condition for one Resident (#2) of three residents reviewed for change in condition, resulting in harm when Resident #2 was transferred to the hospital for mental status changes, found to have a severe wound infection and underwent subsequent intravenous antibiotic administration and surgical intervention. Findings include: Resident #2 (R2) Review of R2's Minimum Data Set (MDS) admission assessment, dated 6/24/2024, revealed the Resident was admitted to the facility on [DATE] and had diagnoses including lumbar fracture, diabetes, anxiety and dementia. Further review of the MDS assessment revealed R2 scored six out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Further review of R2's MDS data revealed R2 was discharged to a short-term stay, acute-care hospital on 9/03/2024.…
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.
- Actual harm · Gcited before2024-03-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 Intake #MI00143052 Based on interview and record review the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for one (resident #3) of one resident reviewed for diabetes management, resulting in diabetic ketoacidosis (emergent condition resulting from prolonged elevated blood sugar levels), hospitalization and death. Findings include: Resident #3 (R3) Review of the Electronic Medical Record (EMR) for R3, revealed the most recent admission to the facility was on 10/20/23 post fall at home with diagnoses including wedge compression fracture T5-T6, pelvis fracture, stage 4 sacral pressure ulcer, severe protein-calorie malnutrition, diabetes type II, peripheral vascular disease, colostomy, chronic kidney disease stage 3 and prior history of neoplasm of large intestine and cervix. R3 was previously admitted from 4/5/23 to 5/20/23 and was familiar to the facility. Review of the discharge summary for admission to the facility from (Regional Acute Care Hospital)…
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 · D2026-04-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
Based on observation, interview, and record review the facility failed to provide assessment, monitoring, and care per facility policy and professional standards for treatment with a nebulizer for one Resident (Resident #2) of one resident reviewed for inhaled medication administration.Findings include: On 4/13/26 at 7:30 PM, during medication administration, Registered Nurse (RN) B was not observed to perform vital signs or respiratory assessment/lung sounds prior or post administration of a nebulized respiratory treatment. RN B did not instruct Resident #2 (R2) to take deep breaths during the treatment and did not remain with resident to observe for change in condition. After completion of the treatment, RN B stated to R2 shh I am trying to listen to your lungs, RN B then leaned closer to the resident. RN B did not have a stethoscope.On 4/13/26 at 7:50 PM, an interview was conducted with RN B regarding assessment pre and post administration of a nebulizer treatment. RN B stated you should listen to lung sounds pre and post treatment. When asked if she had completed a respiratory…
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 before2026-04-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 follow-up to a change in condition according to professional standards of practice for two Residents (#11 and #75) of three resident's reviewed for change in condition. This deficient practice resulted in the potential for complications and worsening of condition.Findings include:Resident #11 (R11) Review of the Minimum Data Set (MDS) assessment, dated 3/24/2026, revealed R11 was admitted to the facility on 3/ 10/2024 and had diagnoses including Type 2 Diabetes Mellitus with hyperglycemia. Review of R11's April 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following physician's orders: Humalog KwikPen (rapid-acting insulin) Subcutaneous Solution Pen-Injector 100 unit/ML [milliliter]. Inject per sliding scale: If 0-199 = 0 units; 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; 400+ = 10 units. If blood sugar is 400 or greater must contact provider . Start 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 · Dcited before2026-04-15 · 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 the facility failed to ensure wound care was completed according to physician order and professional standards of practice for one Resident (#6) of one resident reviewed for pressure ulcers.Findings include:Resident #6 (R6)Review of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's Disease. Review of the Minimum Data Set (MDS) assessment, dated 2/01/2026, revealed R6 had severely impaired cognition and an unhealed, facility-acquired Stage 3 (full-thickness tissue loss) pressure ulcer.Further review of the EMR revealed R6 was currently undergoing daily monitoring for signs and symptoms of sepsis (severe systemic response to infection). Review of the Pertinent Charting - Infections/Signs/Symptoms, dated 4/13/2026 at 3:08 a.m., revealed the following: Follow up to infection signs/symptoms . Site of originally identified infection: sacral wound.Review of the April 2026 Medication…
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 · D2026-04-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor fluids and provide the diet as ordered for one Resident (R99) of three residents reviewed for fluid concerns.Findings include:Resident #99 (R99)The Electronic Medical Record (EMR) for R99 revealed an admission date of 4/9/2026 with diagnoses including : altered mental status, unspecified, chronic kidney disease, essential (primary) hypertension, and retention of urine. The Physician's orders of 4/9/2026 included, Diet order Fluid Restriction-1200 ml (milliliters) diet Regular texture, Regular fluid, thin consistency.The EMR contained a care plan for R99 which included Focus -Resident is at risk for fluid volume deficit related to POST COVID-19 CONDITION, UNSPECIFIED; CHRONIC KIDNEY DISEASE, STAGE 3A Date Initiated: 04/09/2026. The interventions for this care plan included, Encourage resident to drink fluids of choice unless contraindicated (i.e., fluid restriction); assist as needed. The care plan also included, Offer fluids…
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 · D2026-04-15 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician's order for dialysis, monitor a dialysis access site, report dialysis concerns to the physician, care plan potential fluid volume overload, and adhere to physician-prescribed fluid restrictions for one Resident (#8) of one resident reviewed for dialysis.Findings include:Resident #8 (R8)R8 was admitted to the facility on [DATE] with a primary diagnosis of ESRD (End-Stage Renal Disease). A Minimum Data Set (MDS) assessment dated [DATE] documented R8 received hemodialysis treatments at an off-site dialysis facility.Multiple attempts were made to interview R8 on 4/13/26. Registered Nurse (RN) F, the nurse assigned to the unit where R8 resided, said R8 was at dialysis and would be available on 4/14/26.The electronic medical record (EMR) of R8 was reviewed on 4/13/26. The EMR did not contain a physician's order for dialysis. There was no physician's order for monitoring a dialysis vascular access site.Interviews were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to accurately dispense insulin to two Residents (Residents #2, #11) of seven residents reviewed for medication administration resulting in 2 errors in 34 opportunities for error and a 5.88% medication error rate.Findings Include: On 4/13/26 at 7:39 PM, Registered Nurse (RN) B was observed administering insulin to Resident #2 (R2) and held the subcutaneous injection site for six seconds.On 4/13/26 at 7:40 PM, an interview was conducted with RN B regarding how long she was to hold the injection site and replied, Ten seconds. RN B was made aware she only held the needle in place for six seconds. RN B remarked, I must have counted fast .On 4/13/26 at 8:03 PM, RN C was observed administering insulin to Resident #11 (R11) and held the subcutaneous injection site for 5 seconds.On 4/13/26 at 8:05 PM, an interview was conducted with RN C regarding how long she was to hold the injection site and replied, Ten seconds. RN C was made aware she only held the needle in place for five seconds. RN C remarked, I thought I held it…
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 before2026-04-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:Identify appropriate required Transmission Based Precautions (TBP),Obtain a physician's order timely for isolation precautions,Appropriately apply and remove personal protective equipment (PPE),Utilize PPE when indicated, and;Discontinue an antibiotic medication or document justification for continuing antibiotic medication when test results were negative for Resident #2, affecting three Residents (#2, #16, & #12) of six residents reviewed for infection prevention and control.Findings include:Resident #2 (R2) On 4/13/26 at 11:35 AM, a sign for airborne precautions (an isolation measure used to prevent the spread of infectious agents that can be spread through the air over long distances) was observed posted outside the door of R2's room. The airborne precautions sign read: STOP: AIRBORNE PRECAUTIONS. EVERYONE MUST [sic]: Clean their hands, including before entering and when leaving the room. Put on a fit-tested N-95 [filtering facepiece…
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 · D2026-04-15 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 offer and administer COVID vaccinations to two Resident (#2 & #4) of five residents reviewed for immunizations.Findings include:Resident #2 (R2)R2 was admitted to the facility on [DATE]. Vaccination consent forms for pneumococcal and Influenza vaccinations were e-signed by R2 on 1/20/26. A vaccination consent form for COVID-19 was not located in the medical record of R2.A Michigan Care Improvement Registry (MCIR - a statewide immunization information system that tracks vaccinations and health data for residents of Michigan) was reviewed on 4/15/26. The MICR documented R2 was [AGE] years of age. The MCIR indicated the immunization status of the COVID-19 2025-26 vaccine was Overdue.On 4/15/26 at 12:53 PM, Registered Nurse (RN) I was interviewed. RN I confirmed she was responsible for tracking vaccine consents and administrations. RN I said R2 was not provided the COVID-19 vaccination consent form when she was admitted on [DATE].Resident #4 (R4)Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-16 · tag F0880 — failed to prevent and control infections — patternProvide 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 implement safe and effective infection prevention and control (IPC) practices for eight residents (#10, #30, #14, #59, #50, #67, #6, and #65) of ten residents reviewed for IPC to prevent the potential transmission of communicable diseases and infections as evidenced by failure to: 1. Maintain room doors closed for residents with COVID-19. 2. Appropriately sanitize and disinfect contaminated medical equipment. 3. Remove Personal Protective Equipment (PPE) prior to exiting the room of a resident with COVID-19 on Transmission-Based Precautions (TBP). 4. Prepare and handle medications in a manner to prevent contamination. 5. Ensure care plans were initiated for residents with COVID-19. 6. Ensure physicians' orders for were obtained before placing residents in TBP. This deficient practice resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 67 residents in the facility. Findings include: Resident #10 (R10) R10, who was on hospice services,…
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 before2025-01-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 respectful treatment and a dignified dining experience for three Residents (#18, #20, and #58) of five residents reviewed for residents' rights. This deficient practice resulted in the potential for feelings of frustration, embarrassment, and humiliation. Findings include: Resident #18 (R18) R18 was admitted to the facility on hospice services on 9/9/24. The most recent Minimum Data Set (MDS) assessment dated [DATE] documented R18 was dependent on staff for eating. On 1/14/25 at 11:22 a.m., R18 was observed awaiting the lunch meal in the dining room in a high-back mobile reclining chair seated at a table next to the hospice Social Worker (SW). The SW was using a cell phone and laptop computer. The SW was not speaking with or interacting with R18. The SW was drinking from a Styrofoam cup. R18 was not provided or offered fluids while waiting for his meal. R18 sat and watched the SW drinking from the cup and using the cell phone 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.
Show the remaining 10 citations
- Potential for harm · D2025-01-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 appropriately dispose of contaminated medications for three Residents (#61, #50, and #47) of eight residents reviewed for medication administration. Findings include: Resident #61 (R61) During medication preparation for R61 on 1/15/25 at 1:07 p.m., Registered Nurse (RN) H opened a bottle of acetaminophen and dispensed two tablets directly from the bottle into the palm of her hand. RN H said, Oh, I don't want to touch those. RN H disposed of the acetaminophen tablets into the garbage container on the side of the medication cart. Resident #50 (R50) During medication preparation for R50 on 1/16/25 at 7:31 a.m., RN D opened a bottle of vitamins and dropped one on top of the medication cart. RN D picked up the vitamin and disposed of it in the biohazard container on the side of the medication cart. Resident #47 (R47) R47 was prescribed 10 milliequivalents (mEq) of potassium daily. While preparing medication for R47 on 1/16/25 at 7:31 a.m., RN D placed 20 mEq of Potassium in a medication cup for administration 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 · Dcited before2025-01-16 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure two Residents (#47, & #224) of eight residents reviewed for medication administration received the correct dosages of prescribed medications. This deficient practice resulted in a medication error rate of 9.38 % with 3 medication errors detected in 32 opportunities. Findings include: Resident #47 (R47) R47 was prescribed 10 milliequivalents (mEq) of potassium daily. While preparing medication for R47 on 1/16/25 at 7:31 a.m., Registered Nurse (RN) D placed 20 mEq of potassium in a medication cup for administration to R47. The dosage discrepancy was mentioned by the surveyor after medication preparation was completed but before RN D administered the medications to R47. Upon inspection of the blister pack (resident-specific card-type package containing a supply of medication), it was noted RN D had dispensed the 20 mEq of potassium from a blister pack of another resident whose blister pack had been placed in R47's section of the medication cart. RN D said, Someone put the card [blister pack] in the wrong…
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 · D2025-01-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 medications were administered as prescribed for two Residents (R224 and R47) of eight residents reviewed for medication administration. This deficient practice resulted in R224 experiencing excruciating pain and the potential for R47 to experience increased anxiety. Findings include: Resident #224 (R224) R224 was prescribed meloxicam 15 milligrams (mg) daily for pain. During medication administration observation on 1/15/25 at 1:07 p.m., the meloxicam order for R224 was read on the Medication Administration Record (MAR), indicating the medication was overdue to be administered. On 1/15/25 at 1:20 p.m., Registered Nurse (RN) H asked R224 if she was experiencing pain. R224 indicated she had pain in her back and neck. RN H asked R224 to rate the pain on a scale of one to ten with one being no pain and ten being excruciating pain. R224 said her pain was ten out of ten. When asked why the meloxicam had not been administered as scheduled at 8:00 a.m., RN H said the meloxicam was not in the facility emergency…
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 · D2024-09-26 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00146968. Based on interview and record review, the facility failed to provide written notification for a facility-initiated discharge, including the reason, effective dates and right to appeal to the resident's representative and the Office of the State Long-Term Care (LTC) Ombudsman for one Resident (#1) of three residents reviewed for transfer or discharge, resulting in the resident and resident's representative being uninformed of their rights, an unnecessarily extended hospital stay and the potential for inappropriate discharge. Findings include: Resident #1 (R1) Review of the Minimum Data Set (MDS) assessment, dated 7/30/2024, revealed R1 was admitted to the facility on [DATE] with a primary diagnosis of schizophrenia (mental health disorder affecting the ability to think, feel and behave clearly). Review of R1's electronic medical record (EMR) revealed R1 was transferred to the emergency department (ED) for psychological evaluation on 7/30/2024 at 5:01 p.m. with no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-11 · 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 Intake #MI00143052 Based on observation, interview, and record review the facility failed to notify a physician of pressure ulcer condition worsening for one resident (Resident #3) of three residents reviewed for pressure ulcers. This deficient practice resulted in the potential for wound infection and worsening of pressure ulcer. Findings include: Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility on [DATE] after a fall at home with diagnoses including wedge compression fracture T5-T6, pelvis fracture, stage 4 sacral pressure ulcer (PU), severe protein-calorie malnutrition, diabetes type II, peripheral vascular disease, colostomy, chronic kidney disease stage 3, and prior history of cancer of large intestine and cervix. R3 was admitted for rehabilitation. Review of nurse note from 12/17/23 at 3:29 PM, states Wound was done on coccyx. Area has a strong foul odor. There was no indication the provider was notified of strong odor from pressure ulcer on sacrum. On 3/11/24 at 4:00…
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 before2024-02-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 dignified and respectful treatment for one Resident (R11) of three residents reviewed for dignity. This deficient practice resulted in an undignified shower experience and disrespectful treatment. Findings include: Resident #11 (R11) was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety disorder. R11 was identified in the care plan as having a deficit with the ability to perform Activities of Daily Living (ADL) due to weakness and a stroke that left R11 with paralysis on the left side of the body. The care plan documented the resident requires the use of a mechanical lift for transfers. Shower documentation revealed R11 is dependent on staff for showering and getting to and from the shower. On 2/6/24 at approximately 3:20 p.m. Certified Nursing Assistant M (CNA M) was observed pushing a shower gurney on the 600 hall. The surveyor entered the hall behind CNA M. R11 was lying on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plans were updated and revised appropriately for two Residents (R3 and R45) out of 15 Resident care plans reviewed. This deficient practice resulted in care plans which did not reflect resident needs. Findings include: Resident #3 (R3) During an interview on 2/5/24 at 3:41 PM, Resident #3 (R3) stated her bandaged heel hurt. R3 was in her room in her wheelchair. The Electronic Medical Record (EMR) revealed the physician had ordered a treatment for this area on R3's left heal which read: Left heel abrasion; cleanse, apply silicone dressing, qd (every day). During an interview on 2/6/24 at 9:30 AM, Registered Nurse (RN) D wound care specialist performed the wound treatment, and this Surveyor observed the circular pink heal wound. R3 stated it hurt and she believed it was caused from her shoe. RN D suggested to R3 that she not wear shoes but instead grippy socks and continue to wear the soft puffy boots for foot protection when 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 · Dcited before2024-02-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Based on observation, interview, and record review the facility failed to develop timely care plan interventions and implement physician-ordered pressure-alleviation devices to promote healing of wounds for one Resident (R2) of three residents reviewed for wounds. Findings include: On 2/5/24 at 12:34 p.m., Resident #2 (R2) was observed lying in bed in a supine position (lying on the back) with both heels directly on the mattress. R2 said his feet hurt due to a wound on his left heel and a wound where the toes of the right foot used to be. R2 said the five toes on the right foot and two toes on the left foot had been amputated. There were no heel lift devices or bed cradle devices, or other skin protection equipment visualized in the room. When asked if staff used pillows or other equipment under his feet to lift his heels off the bed, R2 said sometimes, when they remember to do it. When asked if staff used equipment to lift the bedcovers from his toes, R2 responded, They've never done that. R2 said he used to have specialized boots, but the boots were misplaced so staff has 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 · Dcited before2024-02-07 · 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, the facility failed to implement interventions to promote the healing of a pressure injury for one Resident (R23) of three residents reviewed for pressure injury. Findings include: Resident #23 (R23) was re-admitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment dated [DATE] coded R23 as having pressure injuries upon admission to the facility. The MDS documented a score of 15/15 on the mental status evaluation indicating R23 was cognitively intact. During an interview on 2/5/24 at 3:59 p.m., R23 said he had a wound on the left heel. R23 was sitting in a wheelchair wearing a pair of gripper socks with both feet placed on the floor. A pair of pressure-reducing wound boots were observed against the wall in the corner of the room. When R23 was asked if he wore the boots, R23 stated the staff had not put them on his feet yet. R23 said he is not able to independently don them, so he doesn't usually wear them. R23 said, I guess I choose not to wear…
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 · D2024-02-07 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 correct therapeutic diet was served as prescribed for 3 of 3 residents (R13, R33, and R40) reviewed for therapeutic diets. This deficient practice resulted in the potential for health complications. Findings include: During the breakfast meal on 2/6/24 at 8:20 AM, the meal cart on the 500 hall was observed and included a breakfast tray for R13. The meal ticket indicated a Diet order: Regular, NAS (No Added Salt) and the tray included a packet of salt. This cart also included a breakfast tray for R40 with a meal ticket which read, Diet order: Regular, NAS and the tray included a packet of salt. The Certified Nurse Aide (CNA) O was asked about the diet order, and she said, That is NAS. They (dietary) should not have given salt on the tray. During the breakfast meal on 2/6/24 at 8:28 AM, the meal cart on the 700 hall was observed and included a breakfast tray for R33. The meal ticket dated [DATE]/24 Breakfast indicated a Diet…
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
$29,348 in federal fines across 1 penalty.
- $29,348 — penalty dated 2024-09-26
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MEDILODGE — 53 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.1 | -1.1 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 52 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 52; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EVEREST OPCO GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2018 |
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2017 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2018 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2018 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 02/01/2018 |
| FLASHNER, CRAIG | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| PERLSTEIN, YITZCHOK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| BLOSSOM HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2016 |
CMS files one row per role, so the 14 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $417K 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
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 235566. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, 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 →
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