The Village of East Harbor
33875 Kiely Drive, Chesterfield Township, MI 48047 · Non profit - Church related · 102 certified beds · (586) 725-6030 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $15,593 in federal fines (most recent 2023-10-04)
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 | 16.9% | 10.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.6% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.6% | 1.5% | 2.0% | worse |
| 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 | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.5% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 27.3% | 12.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.8% | 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 | 4.7% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.2% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.2% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.9% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.0% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.8% | 11.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.11 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.27 | 1.64 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.6% 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 370 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.7% 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 178 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.52 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% 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 | 54.6%CMS range 48.5–59.3 | 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 | 11.9%CMS range 8.6–14.4 | 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 | 42.7% | 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 | 52.8% | 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 | 28.1% | 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 | 94.1% | 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 | 3.6% | 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 | 6.9%CMS range 3.6–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 102 beds and averages 89.1 residents a day — about 87% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.60 hrs/resident/day on weekends vs 4.40 on weekdays — 18% thinner on weekends. RN hours go from 0.82 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-10-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake: MI00136749. Based on interview, and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement for one resident (R901) who had a severe cognitive impairment, was a known elopement risk, and wore a WanderGuard (a bracelet used to set off an alarm restricting a resident from walking out of the door). R901 eloped from the facility on 5/15/2023 at approximately 3:25pm without facility staff being aware of the resident's whereabouts. R901 was allowed to exit the facility by a staff member that was unfamiliar with the resident at approximately 3:25pm. R901 exited through doors that were unequipped with a WanderGuard alarm system, crossed a high traffic four-lane street, while heading toward their house of origin which is approximately 2 miles away from the facility. R901 was found by their neighbors, and driven to the resident's home at approximately 4:46pm. R901 returned to the facility at approximately 5:30pm, combative and agitated. This deficient practice resulted in the likelihood of serious injury,…
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 before2025-12-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 2688079.Based on observation, interview, and record review, the facility failed to ensure two persons assisted with toileting assistance for one (R901) resident of three transfer-dependent residents reviewed for assistance. Findings include: Review of a complaint called into the State Agency revealed a concern from R901's family member that on 11/30/25, after the family member requested toileting assistance for the resident, the resident was manually transferred to the toilet by one staff person then manually transferred from the toilet by two staff rather than via two-person assistance using a mechanical lift as physician ordered.Review of the facility record for R901 revealed they were admitted into the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, and Osteoarthritis. Review of R901's Activities of Daily Living (ADL) care plan revealed the resident required direct assistance with all ADLs including transfers.Review of R901's physician orders revealed…
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 · F2025-04-02 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage for five days of the period from 10/01/24 until 04/01/25 potentially affecting all 92 residents that residen in the facility. Findings include: Review of the Payroll-Based Journal (PBJ) data submission revealed the facility had been identified as having four or more days without adequate RN coverage for the most recent annual quarter. Review of the facility daily nursing staff postings revealed a total of 39 days during the quarter showing no RN hours for the day. The facility Director of Nursing (DON) was made aware of the staff posting days identified as having no RN coverage and was asked to provide any documentation supporting the presence of RN coverage that would not show on the daily posting such as a Minimum Data Set (MDS) RN or Staff Education RN. Documentation supporting additional RN coverage was reviewed including timeclock punch records with staff identifying information. This review verified a total of five days being identified as having no RN…
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 · F2025-04-02 · 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 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 from the kitchen. Findings include: In the dry storage room, there was a buildup of trash on the floor underneath the racks, and the ceiling vent cover was coated with dust. According to the 2017 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. In the walk-in cooler, there was raw beef and raw chicken stored next to fully cooked ham. DM confirmed the meat items were not stored appropriately, and moved the items to a different rack. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure space heaters were not in use for two residents (R49 and R51) out of nineteen residents reviewed for safe, clean, homelike environment. Findings include: R49 On 3/31/25 at 10:36 AM, R49 was observed in bed with a space heater near the room heating and cooling unit. When queried about the space heater R49 stated, We have had to use space heaters in our room since the fall because the heat wasn't working properly. Someone from maintenance brought in the heaters for us to use. The room heating and cooling unit was observed not blowing air. On 4/01/25 at 8:24 AM, two space heaters were observed in use in R49 and R51's room. The room heating unit was not blowing air. On 4/01/25 at 8:28 AM, Licensed Practical Nurse (LPN) A was interviewed regarding R49's room heating unit and said they were not sure how long the room heating unit wasn't working. On 4/01/25 at 3:44 PM, Certified Nursing Assistant (CNA) B was interviewed and said the room…
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 · D2025-04-02 · 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 observation, interview, and record review, the facility failed to ensure a cervical [NAME] and thoracic lumbar support orthotic (TLSO) was properly applied for two residents (R261 and R256) of two residents reviewed for protective orthotic devices. Findings include: R261 On 3/31/2025 at 10:49 AM, R261 was observed sitting in a wheelchair in their room with a rigid cervical collar in place. The chin portion of the collar was approximately 3 inches to the left of her chin. R261 was also observed with a left arm sling. The arm sling straps were across the right side, bottom of the rigid collar. R261 was observed moving their head side to side. There was no support to her chin which would allow her to nod her head forward. An inquiry to their comfort revealed the collar is uncomfortable. A review of the electronic medical record (EMR) revealed R261 was admitted to the facility on [DATE] with the following pertinent diagnoses: Non-displaced fracture of the first cervical vertebra, fracture of surgical neck…
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 before2025-04-02 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to label and store medication properly in one of four medication carts and in one (R3) of one resident room. Finding include: On 3/31/25 at 09:57 AM, an observation of Brimonidine Tartrate Ophthalmic eye drops were located on the overbed table of R3. The medication was not labeled with R3's name and was available to anyone passing by. Review of the physician orders did not reveal an order for self administration. On 4/1/2025 at 10:45 AM, in top drawer of Cart 2 on 300 Hall, there was a previously opened bottle of Nuplazid 34 without an open date. On 4/1/2025 at 7:30 AM, an interview with Licensed Practical Nurse (LPN) H revealed upon inquiry no eye drops or medications of any kind should be at resident bedside. On 4/1/2025 at 8:15 AM, an interview with LPN I upon inquiry revealed the medication that was not labeled should have been dated and labeled when opened.
- Potential for harm · E2024-04-18 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document and include residents and resident representatives in care conferences for six residents (R1, R4, R21, R26, R47, R50) of seven residents reviewed for care planning participation. Findings include: Resident #50 (R50) On 4/18/24 at 9:06 AM, a review of R50's electronic medical record (EMR) ninety day review of R50's care conferences revealed no documentation of R50 being invited and included in their care conferences on 10/24/23, 1/12/24, and 4/11/24. On 4/18/24 at 9:13 AM, a further review of R50's EMR revealed that R50 was originally admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes and Schizoaffective disorder. R50's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R50 had a moderately impaired cognition. On 4/18/24 at 11:23 AM, R50 was interviewed regarding their level of participation and invitations to their care conferences at the facility. R50 stated, I've never been invited…
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 · E2024-04-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide six residents, who wish to remain anonymous and regularly attend the resident council meetings, with the grievance procedure or document resolution of concerns identified during the resident council meetings. Findings include: On 04/17/24 at 1:30 PM, the six residents in attendance at the resident council meeting were asked if they had been informed about the grievance procedure and how to file a grievance and all denied a working knowledge of the process. The residents agreed all complaints had been verbal and written follow up or resolution was not provided. The residents had voiced repeated concerns with staffing agency and nighttime staff not wearing name badges, unmet care needs, being left for extended periods on the toilet, clothes damaged, call light wait times, staff coming in and turning off the call light and not coming back, or poor attitude from staff. There were also questions on resident rights. A review of the Resident Council…
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 · D2024-04-18 · 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
Based on observation, interview, and record review, the facility failed to implement interventions from the fall care plan for one resident (R32) out of three reviewed for care plan interventions. Findings include: On 4/16/2024 at 9:20 AM, R32 was interviewed regarding their care in the facility. R32 stated that they had just moved to the long-term care side. R32 stated that they had a broken hip that is healing nicely. R32 stated they often transfer themselves, but the staff try and remind them to use the call light. A review of the medical record revealed that R32 admitted into the facility on 3/17/2024 with the following diagnoses, Fracture of Right Femur, Muscle Weakness, and Difficulty in Walking. Further review of the Minimum Data Set assessment (MDS) revealed a Brief Interview for Mental score of 10/15 indicating an impaired cognition. R32 also required one person assist with bed mobility and transfers. A review of the fall risk assessment revealed that R32 was a high fall risk. Further review of the care plan revealed the following fall interventions, I have a landing strip…
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 before2024-04-18 · 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 inhalers were labeled with a resident identifier and dated when opened in one of four medication carts. Findings include: On 04/17/24 at 8:54 AM, in the Michigan 2A medication cart, one Trelegy inhaler did not have the name or the date opened on the inhaler; Two of the three other Trelegy inhalers did not have the name and the third did not have a date on the inhaler. On 04/18/24 at 3:58 PM, the Director of Nursing (DON) was asked about label and dates on inhalers and reported, My expectation is to date and initial; with the date opened and resident initials. A review of the facility policy titled, Medication Storage with last reviewed date of 04/24, revealed, Policy: It is the policy of (the facility) to store medications properly in accordance with clinical best practice and according to drug manufacturer instructions . 3. Date opened: All flushes, multi-dose Vials, irrigation solution and IV fluids must be marked with date opened or first used . 5. Inhalers: Store in the original box from pharmacy.…
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 6 citations
- Potential for harm · D2023-03-29 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 full visual privacy was provided during a blood draw for one resident (R67) of one reviewed for privacy concerns, resulting in a concern for privacy and potential embarrassment. Findings include: On 03/28/23 at 9:08 AM, R67 was observed to be seated in their wheelchair in the dining room on the [NAME] unit. Additional residents were observed eating their meals. R67 was away from the main dining table at one end of the sofa. R67 had their back to the hall and was seated with the phlebotomist (technician that collects blood). The phlebotomist cart was next to them and R67 was in the process of having their blood drawn. 03/29/23 at 9:20 AM, R67 was asked resident about their blood having been drawn in the dining area and reported it was one of those things that should be done in their room. R67 reported they felt they were not given a choice to return to their room. R67 further reported on query that the phlebotomist had excuses for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review, the facility failed to develop and/or implement the care plan for 1. wrist/hand splint (R5) and 2. frequency of resident repositioning for two (R15, R54) of three residents reviewed for repositioning, resulting in the potential for contractures and new or worsened skin breakdown. Findings include: R5 Review of the facility record for R5 revealed an admission date of 2/23/21 with diagnoses that included Multiple Sclerosis and Muscle Weakness. The Minimum Data Set (MDS) assessment dated [DATE] indicated R5 required set up for eating and was dependent for self care otherwise. The Brief Interview for Mental Status (BIMS) score was 15/15 indicating intact cognition. On 3/27/23 at 12:21 PM, It was observed that R5's right wrist was resting in an extended (bent backwards) position. R5 was not wearing any type of splint or orthosis and one was not observed in the room. On 3/28/23 at 10:40 AM, R5 was observed with the right wrist maintained in extension. When asked…
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 before2023-03-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 meet the care needs of a resident (R36) out of five reviewed for Activities of Daily Living (ADL's), resulting being left soiled for an extended time. Findings include: On 3/27/23 at 9:41 AM, R36 was observed in bed and watching television. R36's bed sheets were observed to have a large brown stained area that went down the side of R36's leg. The stain appeared to be from a bowel movement (BM). R36 was asked if staff had been in to see them and stated, No. I just woke up. On 3/27/23 at 10:42 AM, R36 was observed in the same condition as before, soiled with BM through the sheets. R36 was asked if they had been changed and stated, Not yet. They will be in. On 3/27/23 at 12:18 PM, R36 was observed in the same condition, R36 explained that staff had not come in to change them. On 3/27/23 at 12:45 PM, Licensed Practical Nurse (Nurse B) was asked to observe R36 sheets. LPN B stated, Looks like you had a BM and need to be cleaned up. R36…
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 · D2023-03-29 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed place a splint on one resident (R13) out of two reviewed for contractions, resulting in the potential for worsening of a contracture and pain. Findings include: On 3/29/2023 at 9:45 AM, an interview was conducted with R13 regarding their contractures. R13 stated that they can barely open their left hand now and their right hand is starting to do the same. R13 was observed trying to open their left hand and was unable to. R13 stated that they would like to be able to clasp their hands together to pray. On R13's night stand a splint was observed sitting in a basin. R13 stated that they are supposed to wear one during the day and one at night. R13 stated that they need help applying them, but they can't remember the last time they wore them. A review of the medical record revealed that R13 admitted into the facility on 3/3/2020 with the following diagnoses, Post polio Syndrome, Contracture Left Hand, and Contracture Right Foot. A review of the Minimum Data Set (MDS) assessment revealed a Brief Mental Status (BIMs)…
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 before2023-03-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall interventions (gait belt) for one resident (R243) out of two residents reviewed for falls, resulting in the potential for increased falls. Findings include: On 3/27/2023 at 12:27 PM, R243 was observed being taken to their room. R243 was being pulled in the wheelchair backwards, with their feet dragging on the ground. R243 was then observed being transferred into the bed by their arms, a gait belt was observed to be hanging on the back of the wheelchair. R243 was halfway to the floor and unable to completely bear weight on their legs. A review of the medical record revealed that R243 admitted into the facility on 6/7/2021 with the following diagnoses, Parkinson's Disease, Muscle Weakness, and Difficulty in Walking. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9/15 indicating an impaired cognition. R243 also required extensive one…
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 · D2023-03-29 · 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
Based on observation, interview, and record review, the facility failed to follow a special diet order for one resident (R65) out of one reviewed for nutrition, resulting in R65 receiving a straw in their water and the increase potential for choking. Findings include: On 3/27/2023 at 10:50 AM, R65's room was observed with a sticker that read no straws. Upon entering R65's room, their water cup was noted to have a straw in it. On 3/27/2023 at 10:58 AM, Licensed Practical Nurse (LPN) E was informed that R65 had a straw in their water cup. LPN E stated that R65 is not supposed to have a straw in their cups due to a choking issue. LPN E then took the straw out the cup. On 3/29/2023 at 11:40 AM, an interview was conducted with the Director of Rehabilitation (DOR) regarding R65 having a straw in their drink cup. The DOR stated that R65 has previously had a stroke and has frequent fluctuations in their swallowing. The DOR stated that R65 had been ordered no straws for a long time for safety because straws speed up the process of swollowing the liquid . A review of a facility policy titled,…
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
$15,593 in federal fines across 1 penalty.
- $15,593 — penalty dated 2023-10-04
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PRESBYTERIAN VILLAGE EAST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/08/1993 |
| PRESBYTERIAN VILLAGES OF MICHIGAN | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/08/1993 |
| MYERS, ROGER | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/08/1993 |
| MILLER, DAVID | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 04/07/1987 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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 $1.4M 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 235528. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-02, 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.